A nurse is caring for a client who has angina and reports a feeling of heaviness in the chest while ambulating in the hall. Which of the following actions should the nurse take first?
Obtain a 12-lead ECG for the client.
Administer sublingual nitroglycerin to the client.
Measure the client's vital signs.
Have the client stop walking and sit down.
The Correct Answer is D
Rationale:
A. Obtain a 12-lead ECG for the client: An ECG is important to assess for myocardial ischemia or infarction, but it should be done after immediate measures are taken to reduce myocardial oxygen demand.
B. Administer sublingual nitroglycerin to the client: Nitroglycerin helps relieve chest pain by dilating coronary arteries, but it should be given only after the client is safely seated or resting to prevent hypotension or injury.
C. Measure the client's vital signs: Vital signs provide valuable baseline data, but addressing the client’s immediate safety and reducing cardiac workload takes priority.
D. Have the client stop walking and sit down: Stopping activity decreases oxygen demand on the heart and prevents worsening ischemia or collapse, making it the first and most critical action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Hold the sterile package in his dominant hand and open the top flap of the package toward his body: The top flap should be opened away from the nurse’s body to avoid reaching over and contaminating the sterile field. Opening toward the body risks touching or dropping contaminants onto the field.
B. Drop the sterile gauze from 25.4 cm (10 in) above the sterile field: Sterile items should be dropped from a minimal height, close to the field, to prevent them from bouncing, falling off, or becoming contaminated. A 10-inch drop increases the risk of contamination.
C. Place objects 1.27 cm (0.5 in) inside the border of the sterile field: The outer 1 inch (2.5 cm) of a sterile field is considered contaminated, not just 0.5 inches. Placing objects inside only 0.5 in does not guarantee sterility and may result in contamination.
D. Position the bottle outside the edge of the sterile field when pouring solution into a sterile container: Keeping the bottle outside the sterile field prevents contamination from the outside of the bottle. Only the sterile contents should enter the sterile container, maintaining the integrity of the sterile field during the dressing change.
Correct Answer is D
Explanation
Rationale:
A. Call in additional medical-surgical unit nursing care staff: Calling in staff may be part of the overall disaster plan but is typically coordinated by administration or the incident command team, not by individual unit nurses.
B. Act as a liaison between the facility and the media: Communication with the media is the responsibility of the facility’s public information officer or designated spokesperson, not bedside nurses.
C. Determine the medical needs of incoming clients through the emergency department: Triage and assessment of incoming clients occur in the emergency department by the triage nurse or emergency staff, not on the medical-surgical unit.
D. Recommend to the provider specific acute care clients for discharge: In a mass casualty event, medical-surgical nurses help identify stable clients who can be safely discharged or transferred to make room for incoming critical clients. This is an essential role in surge capacity management.
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.