A client with coronary artery disease complains of chest pain while brushing their teeth in the bathroom. Which action should the nurse implement first?
Perform a 12-lead electrocardiogram and call a rapid response.
Withhold the client's medications until the healthcare provider arrives.
Instruct the client to stop the activity and provide a chair.
Call the healthcare provider immediately about the client's complaint.
The Correct Answer is C
Choice A reason: Performing a 12-lead electrocardiogram and calling a rapid response is not the first action that the nurse should take. A 12-lead electrocardiogram is a test that measures the electrical activity of the heart and can help diagnose a heart attack or other cardiac problems. ¹ A rapid response is a team of healthcare professionals that can provide immediate care to a client who is experiencing a life-threatening emergency. ² However, these actions are not the priority for a client who has chest pain while brushing their teeth. The nurse should first assess the client's condition and provide comfort measures before performing any tests or calling for help.
Choice B reason: Withholding the client's medications until the healthcare provider arrives is not the first action that the nurse should take. The client's medications may include drugs that can relieve chest pain, such as nitroglycerin, aspirin, or beta-blockers. ³ These drugs can help dilate the blood vessels, prevent blood clots, or reduce the workload of the heart. ³ The nurse should not withhold these medications, as they may help the client's condition and prevent further complications. The nurse should check the client's medication orders and administer them as prescribed.
Choice C reason: Instructing the client to stop the activity and provide a chair is the first action that the nurse should take. Chest pain is a common symptom of coronary artery disease, which is a condition where the arteries that supply blood to the heart become narrowed or blocked by plaque. ⁴ Chest pain can be triggered by physical or emotional stress, such as brushing the teeth, which can increase the heart rate and blood pressure. ⁵ The nurse should instruct the client to stop the activity and provide a chair, as this can help reduce the stress on the heart and ease the chest pain. The nurse should also monitor the client's vital signs and oxygen saturation, and provide oxygen if needed.
Choice D reason: Calling the healthcare provider immediately about the client's complaint is not the first action that the nurse should take. The healthcare provider may need to be notified about the client's condition, especially if the chest pain is severe, persistent, or accompanied by other symptoms, such as shortness of breath, nausea, or sweating. ⁵ However, the nurse should first assess the client's condition and provide comfort measures before calling the healthcare provider. The nurse should also be prepared to initiate emergency protocols if the chest pain does not improve or worsens.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Decreased hair is most likely a hereditary condition and nail changes are related to fungus is not the statement that describes the cause of this finding. This statement is not based on evidence and does not explain the relationship between peripheral vascular disease and the observed changes in the legs and feet.
Choice B reason: A blood clot may be forming and the client needs immediate intervention is not the statement that describes the cause of this finding. This statement is an alarmist and inaccurate interpretation of the finding. A blood clot would cause more acute and severe symptoms, such as pain, swelling, redness, and warmth in the affected area.
Choice C reason: Decreased oxygen to the tissues causes changes in hair growth and nail texture is the statement that describes the cause of this finding. This statement is based on the pathophysiology of peripheral vascular disease, which is a chronic condition that reduces the blood flow to the extremities due to atherosclerosis or inflammation of the blood vessels. The reduced blood flow leads to tissue ischemia and necrosis, which can manifest as hair loss, thickening and yellowing of the nails, skin ulcers, and gangrene.
Choice D reason: Depending on the client's age, the findings may be normal is not the statement that describes the cause of this finding. This statement is a vague and dismissive response that does not address the underlying problem of peripheral vascular disease. The findings are not normal for any age group and require further assessment and intervention.
Correct Answer is D
Explanation
Choice A reason: Respiratory alkalosis is not the correct answer. Respiratory alkalosis is a condition where the blood pH is high (above 7.45) due to low carbon dioxide levels (below 35 mmHg) caused by hyperventilation. The client's blood pH is low (7.2) and the carbon dioxide level is normal (40 mmHg), which does not indicate respiratory alkalosis.
Choice B reason: Metabolic alkalosis is not the correct answer. Metabolic alkalosis is a condition where the blood pH is high (above 7.45) due to high bicarbonate levels (above 26 mEq/L) caused by excessive loss of acids or intake of alkali. The client's blood pH is low (7.2) and the bicarbonate level is low (19 mEq/L), which does not indicate metabolic alkalosis.
Choice C reason: Respiratory acidosis is not the correct answer. Respiratory acidosis is a condition where the blood pH is low (below 7.35) due to high carbon dioxide levels (above 45 mmHg) caused by hypoventilation. The client's blood pH is low (7.2) but the carbon dioxide level is normal (40 mmHg), which does not indicate respiratory acidosis.
Choice D reason: This is the correct answer. Metabolic acidosis is a condition where the blood pH is low (below 7.35) due to low bicarbonate levels (below 22 mEq/L) caused by excessive production or intake of acids or loss of alkali. The client's blood pH is low (7.2) and the bicarbonate level is low (19 mEq/L), which indicates metabolic acidosis.
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