A client was admitted 2 days ago with pneumonia. The client is now having chest pain. Vital signs are Temperature 37.2 C (98.9 F), Pulse 108, Blood pressure 160/90, respirator rate 24, and Oxygen Saturation 90%. What should the nurse do first?

Call another nurse for help

Give pain medication as ordered

Call the admitting healthcare provider

Tell client to remain calm

Apply oxygen via nasal cannula as ordered

Answer and Explanation

The Correct Answer is E

A. Calling another nurse for help is unnecessary unless additional assistance is required after initial interventions.
B. Giving pain medication as ordered may address the chest pain but does not address the immediate need for oxygenation.
C. Calling the admitting healthcare provider can be done later if symptoms do not improve, but the immediate priority is to improve oxygenation.
D. Telling the client to remain calm may help reduce anxiety but does not address the low oxygen saturation.
E. Applying oxygen via nasal cannula as ordered is the priority action to improve the client’s oxygen saturation and alleviate hypoxemia, which could be contributing to their chest pain.

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Correct Answer is D

Explanation

A. Hyperresonance is often heard in cases of pneumothorax or emphysema, not pneumonia.
B. Bubbling is not a percussed sound but rather a description of breath sounds or fluid.
C. Tympany is typically heard over hollow organs like the stomach and is not expected in lung assessment.
D. Dullness over lung tissue indicates fluid or consolidation, as seen in pneumonia.
E. Resonance is normal over healthy lung tissue but would not be expected over areas of consolidation.

A. Enlargement of the heart ventricle B. Turbulent blood flow C. Persistently slow heart beat D. Extreme pulse deficit E. Coronary artery blockage

Correct Answer is A

Explanation

A. A heave (or lift) often indicates ventricular hypertrophy or enlargement, suggesting increased workload on the heart.
B. Turbulent blood flow may lead to murmurs but is not specifically associated with a heave.
C. A persistently slow heartbeat is referred to as bradycardia and does not correlate with a heave.
D. An extreme pulse deficit relates to discrepancies between heartbeats and palpable pulses but is not linked to a heave.
E. Coronary artery blockage would not directly produce a heave; it typically leads to ischemic changes.

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A client was admitted 2 days ago with pneumonia. The client is now having chest pain. Vital signs are Temperature 37.2 C (98.9 F), Pulse 108, Blood pressure 160/90, respirator rate 24, and Oxygen Saturation 90%. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is percussing over the lungs of a client with pneumonia. What sound will the nurse expect to hear?

Correct Answer is D

Explanation

When performing a focused cardiac assessment on a newly admitted client, the nurse notes a heave on the left side of the chest. What can a heave signify?

Correct Answer is A

Explanation

When auscultating the lungs of an adult client, the nurse notes that low-pitched, soft breath sounds are heard over the lower lobes. How would the nurse interpret these findings?

What subjective data should the nurse obtain about a client's cardiac status? Select all that apply.

The nurse obtains information when performing a focused assessment of a client with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea (shortness of breath) over the last 3 days. Which finding is most important to report to the health care provider?

A nurse is performing a cultural assessment using the LEARN mnemonic for communication. Which area will the nurse assess for the "L" portion of the mnemonic?

When assessing tactile fremitus, increased tactile fremitus is expected under which condition?

The nurse is assessing a 1-day post-operative client and discovers fine crackles at the bases of the right lung on inspiration. What does the nurse suspect is the cause of the adventitious lung sounds in the right lung?

When teaching a health promotion class at a retirement home for individuals 65 or greater, which information would the nurse include about ways to decrease the spread of respiratory infections?