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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The inability to locate a dorsalis pedis pulse and increasing pain indicate compromised circulation, which requires immediate attention to prevent complications.
Choice B rationale
Pain relieved after administering medication indicates effective pain management, which is not an urgent issue to report immediately.
Choice C rationale
Generalized weakness and increasing sensitivity to touch can be concerning but are not as urgent as signs of compromised circulation.
Choice D rationale
Localized edema and discoloration are expected findings in a fracture and are not as urgent as an absent pulse. .
Correct Answer is A
Explanation
Choice A rationale
A terminal ileostomy involves creating an opening in the right lower quadrant of the abdomen where the ileum is brought to the surface to form a stoma for waste elimination.
Choice B rationale
The left lower quadrant is not used for a terminal ileostomy, as it is not anatomically appropriate for the ileum.
Choice C rationale
The right upper quadrant is not relevant to a terminal ileostomy because the ileum is located in the lower part of the abdomen.
Choice D rationale
The left upper quadrant is also inappropriate for a terminal ileostomy due to the anatomical position of the ileum.
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