A client one (1) day postoperative for coronary artery bypass graft (CABG) reports chest pain.
Which intervention should the nurse implement first?

Notify the healthcare provider.

Assess the client's vital signs and check the telemetry monitor.

Encourage the client to take deep breaths.

Administer pain medication immediately.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Notifying the healthcare provider is necessary, but assessing the client's condition comes first to provide relevant information.

Choice B rationale

Assessing the client's vital signs and telemetry monitor is the first step to determine the cause of chest pain and ensure it is not due to a life-threatening issue such as myocardial infarction.

Choice C rationale

Encouraging the client to take deep breaths can be helpful but is not the first priority. It addresses pain related to breathing but not the underlying cause.

Choice D rationale

Administering pain medication is important, but only after determining the cause of the chest pain and ruling out serious complications.

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Correct Answer is B

Explanation

Choice A rationale

Nasal congestion is not a symptom associated with acute cystitis. Acute cystitis primarily affects the urinary system.

Choice B rationale

Dysuria, which means painful or difficult urination, is a common symptom of acute cystitis, as it involves inflammation of the bladder and urethra.

Choice C rationale

Shortness of breath is not a typical symptom of acute cystitis. Acute cystitis symptoms are localized to the urinary tract.

Choice D rationale

Joint pain is not associated with acute cystitis. The symptoms of acute cystitis are related to the urinary system.

A. Dorsalis pedis pulse cannot be located with a doppler and increasing pain. B. Pain relieved after administering 4 mgs of hydromorphone. C. Generalized weakness and increasing sensitivity to touch. D. Localized edema and discoloration of the affected limb.

Correct Answer is A

Explanation

Choice A rationale

Inability to locate the dorsalis pedis pulse and increasing pain are signs of compromised circulation, requiring immediate intervention.

Choice B rationale

Pain relieved by medication does not indicate an urgent situation and suggests effective pain management.

Choice C rationale

Generalized weakness and increased sensitivity to touch are not typically indicative of a critical emergency requiring immediate reporting.

Choice D rationale

Localized edema and discoloration are expected findings following a fracture and do not necessitate immediate reporting.

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A client one (1) day postoperative for coronary artery bypass graft (CABG) reports chest pain.Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

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A client one (1) day postoperative for coronary artery bypass graft (CABG) reports chest pain.
Which intervention should the nurse implement first?