A nurse is caring for a client who experienced a femur fracture 8 hr ago and now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first?
Provide high-flow oxygen.
Administer an IV vasopressor medication.
Monitor the client for headache.
Check the client for a positive Chvostek's sign.
The Correct Answer is A
A. Provide high-flow oxygen
The client may have a fat embolism. Oxygenation is the priority to prevent hypoxia and support vital organs.
B. Administer IV vasopressor
Vasopressors may help hypotension, but oxygenation comes first.
C. Monitor for headache
Headache is not the primary concern here.
D. Check for Chvostek’s sign
Chvostek’s sign is for hypocalcemia, unrelated to this emergency.
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Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
A. Insert a nasogastric (NG) tube.
Not part of the first-hour sepsis bundle; used for gastric decompression or nutrition later if needed.
B. Obtain blood cultures.
Cultures must be drawn before antibiotics to identify the causative organism.
C. Rapidly administer 30 mL/kg of normal saline.
Initial fluid resuscitation is essential to correct hypotension and improve perfusion.
D. Measure lactate level.
Elevated lactate indicates tissue hypoperfusion and helps guide treatment effectiveness.
E. Administer broad-spectrum antibiotics.
Timely antibiotics reduce mortality; must be given within 1 hour.
F. Obtain a urine specimen.
May help identify infection source, but not a priority in the first hour.
G. Obtain a wound culture.
Can be done later; blood cultures are the priority in sepsis.
H. Type and cross-match for 2 units of packed RBCs.
Only needed if there's evidence of hemorrhagic shock or anemia, which is not the case here.
Correct Answer is D
Explanation
A. Slow
AFib may be slow, normal, or fast depending on rate control, so this is not always expected.
B. Not palpable
Pulses are usually present but irregular.
C. Bounding
Not typical of AFib.
D. Irregular
A hallmark feature of AFib is an irregularly irregular pulse.
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