A client expresses anger when the nurse does not respond within 5 minutes of ringing for the nurse. Which response by the nurse is appropriate?

Choice A rationale

Using an extension cord to watch television in the living room does not indicate effective learning about using a walker. Extension cords can create a tripping hazard, which is particularly dangerous for someone using a walker.

Choice B rationale

Hiring someone to trim the tree that overhangs the front porch stairs indicates an understanding of the need to remove potential obstacles that could interfere with the safe use of the walker.

Choice C rationale

Placing the alarm clock on the bedroom dresser does not demonstrate an understanding of how to use a walker safely. It does not address any of the key safety considerations associated with walker use.

Choice D rationale

Replacing the old throw rug in the kitchen with a new one does not necessarily indicate effective learning about using a walker. Throw rugs can be a tripping hazard for individuals using a walker, regardless of whether they are old or new.

Choice A rationale: Initiating a cardiac enzyme panel can help determine if the client has had a heart attack. However, this is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first. An ECG can provide immediate information, while a cardiac enzyme panel takes longer to return results.

Choice B rationale: Starting intravenous fluid therapy may be necessary depending on the client’s hydration status and overall condition. However, it is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first.

Choice C rationale: Providing pain relief medication may be necessary if the client is in pain. However, the client’s primary complaint is chest tightness and difficulty breathing, not pain. Therefore, addressing the potential cardiac issue is the priority.

Choice D rationale: The client’s symptoms of sudden shortness of breath, chest tightness, and anxiety, along with her history of hypertension and diabetes, are concerning for a possible cardiac event. An electrocardiogram (ECG) can provide immediate information about the heart’s electrical activity and help identify if the client is experiencing a heart attack or other cardiac event. This should be the first action taken to quickly identify the cause of the client’s symptoms and initiate appropriate treatment.

Choice E rationale: Performing a comprehensive physical assessment is an important part of nursing care. However, in this situation, the client’s symptoms indicate a need for immediate intervention to address her potential cardiac issue.

Choice F rationale: Monitoring the client’s blood glucose levels is important given her history of diabetes. However, this is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first.