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
Hypokalemia is a potential concern with diuretic therapy, but not with hypertonic saline solution (3% NaCl) administration for hyponatremia.
Choice B rationale
Hypovolemia is less likely to occur with hypertonic saline infusion. The main concern is overcorrection leading to fluid overload.
Choice C rationale
Fluid overload is a significant risk when administering hypertonic saline (3% NaCl). Nurses should closely monitor for signs of fluid overload, such as edema, crackles in the lungs, and increased blood pressure.
Choice D rationale
Hypernatremia is a possible complication of hypertonic saline administration, but it is not as immediate a concern as fluid overload. Monitoring for fluid overload should take precedence.
Correct Answer is C
Explanation
Choice A rationale
A puncture or rupture of the lung is typically associated with a pneumothorax, not flail chest. Pneumothorax occurs when air leaks into the space between the lung and the chest wall.
Choice B rationale
The presence of air or gas in the pleural cavity is known as pneumothorax. Flail chest, however, is characterized by multiple rib fractures.
Choice C rationale
Flail chest occurs when multiple adjacent ribs are fractured in multiple places, creating a free-floating segment of the chest wall. This condition is serious and often results from blunt chest trauma.
Choice D rationale
The collapse of the lung is known as atelectasis or pneumothorax, not flail chest. Flail chest specifically refers to the detachment of a segment of the rib cage.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.