A client presents to the emergency department with complaints of severe chest pain. Which actions should the nurse implement first?

Call the cardiac catheterization lab and give report to transfer the client.

Administer atenolol 25 mg po.

Assess vital signs and obtain a 12-lead EKG.

Call a rapid response.

Answer and Explanation

The Correct Answer is C

A. Call the cardiac catheterization lab and give report to transfer the client: This action is premature. Before considering a transfer to the catheterization lab, the nurse should first assess the patient to determine the severity and nature of the chest pain, which can help identify if the pain is related to a cardiac issue, such as an acute myocardial infarction (MI), and to guide further interventions.

B. Administer atenolol 25 mg po: While beta-blockers like atenolol may be part of the treatment plan for patients with chest pain, administering oral medication (PO) is not appropriate in an emergency situation, especially if the patient is experiencing severe chest pain. Immediate action should focus on assessment and stabilizing the patient before administering medications.

C. Assess vital signs and obtain a 12-lead EKG:The first priority is to assess the patient’s condition. Vital signs provide important information about the patient's hemodynamic status, and obtaining a 12-lead EKG is crucial for diagnosing acute myocardial infarction (MI) or other heart-related conditions. The EKG will help identify any abnormal rhythms or signs of ischemia, which will guide the treatment plan.

D. Call a rapid response: While calling a rapid response may be necessary if the patient's condition worsens or if they become unstable, the first step should be to assess the patient thoroughly. If the patient's condition deteriorates during the assessment, a rapid response may be called.

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Correct Answer is C

Explanation

A. The ABG results are pH 7.41, PaO2 93, PaCO2 35, and HCO3 24: These ABG values are all within normal ranges:
pH 7.35–7.45 (normal)
PaO2 80–100 mmHg (normal)
PaCO2 35–45 mmHg (normal)
HCO3 22–26 mEq/L (normal)
These results indicate stable respiratory function and do not warrant immediate intervention.
B. The client's pulse oximeter reading is 91% with a consistent waveform: While 91% is slightly lower than the ideal oxygen saturation (usually above 92%–94%), it is still above the critical threshold of 90%. This could be an acceptable level in some patients on a ventilator, particularly if there are no signs of distress or other abnormalities.
C. There is no manual resuscitation bag at the client's bedside: This is a critical situation. A manual resuscitation bag (Ambu bag) is essential for emergency resuscitation if the ventilator fails or if there is an unexpected issue with the patient's airway. Not having a manual resuscitation bag at the bedside is a safety concern that warrants immediate intervention, as it could delay life-saving measures in an emergency.
D. The patient is receiving continuous IV sedation at 150 mL/hr. There's currently 100 mL remaining of the infusion: While it's important to monitor IV sedation infusions, this situation does not immediately warrant intervention. The nurse can track the remaining infusion and ensure there is an adequate supply or order a new infusion if necessary.

A. pulmonary edema B. atelectasis C. bronchoconstriction D. upper airway blockage

Correct Answer is B

Explanation

A. Pulmonary edema: Pulmonary edema is a condition where fluid accumulates in the lungs, typically due to heart failure or other conditions that increase pressure in the blood vessels of the lungs. While pulmonary edema may occur in ARDS, the primary issue in ARDS related to surfactant damage is not fluid accumulation in the lungs but the inability of the lungs to properly expand and maintain gas exchange.

B. Atelectasis: In ARDS, damage to the lung cells that produce surfactant impairs the lungs' ability to maintain surface tension in the alveoli. Surfactant is a substance that helps keep the alveoli open by reducing surface tension. Without sufficient surfactant, the alveoli can collapse, leading to atelectasis (collapse of the alveoli), which further impairs oxygen exchange and contributes to hypoxemia in ARDS.

C. Bronchoconstriction: Bronchoconstriction refers to the narrowing of the airways due to muscle contraction, often seen in conditions like asthma. While bronchoconstriction may occur in other respiratory conditions, it is not the primary pathologic process in ARDS. ARDS is primarily characterized by damage to the alveolar-capillary membrane and impaired surfactant production, leading to atelectasis and impaired gas exchange.

D. Upper airway blockage: Upper airway blockage refers to an obstruction in the airway above the level of the trachea, often due to foreign objects, swelling, or other causes. This is not the primary concern in ARDS, which is a lower respiratory issue affecting the alveoli and gas exchange in the lungs.

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A client presents to the emergency department with complaints of severe chest pain. Which actions should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

A patient is on a ventilator. Which situation warrants immediate intervention by the nurse? ABG pH 7.35-7.45 pa02 80-100 mg Hg PC02 35-45 mm Hg PHCO3 22-26meQ/L

Correct Answer is C

Explanation

During acute respiratory distress syndrome (ARDS), the client's lung cells that produce surfactant have become damaged. The nurse knows this pathologic change will lead to what outcome?

Correct Answer is B

Explanation

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