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 C
Explanation
Choice A rationale
While heartburn can occur shortly after eating, it is the frequent episodes of heartburn and regurgitation that are more commonly associated with hiatal hernia.
Choice B rationale
Dysphagia (difficulty swallowing) and odynophagia (painful swallowing) can occur with other esophageal conditions but are not the primary symptoms of hiatal hernia.
Choice C rationale
Frequent bouts of heartburn and regurgitation after food intake are classic symptoms of hiatal hernia, due to the herniation of the stomach through the diaphragm allowing acid to reflux into the esophagus.
Choice D rationale
Bloating and postprandial fullness can occur, but they are not as commonly associated with hiatal hernia as heartburn and regurgitation.
Correct Answer is D
Explanation
Choice A rationale
Visible signs of bone healing on an X-ray would not be expected after Buck's traction. Healing takes longer to become visible on an X-ray.
Choice B rationale
Increased swelling and redness would indicate complications such as infection or thrombophlebitis, not the effectiveness of traction.
Choice C rationale
Improved range of motion would not typically be expected while Buck's traction is in place. The primary purpose is to reduce pain and immobilize the fracture.
Choice D rationale
Decrease in hip pain is a direct indicator of the effectiveness of Buck's traction in alleviating symptoms and preventing further injury to the fractured femur.
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