A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of the following actions should the nurse take first

Place the client on bedrest.

Obtain the client's ABG levels.

Elevate the head of the client's bed.

Prepare the client for a ventilation-perfusion scan

Answer and Explanation

The Correct Answer is C

A. Place the client on bedrest: While limiting the client’s activity is important to reduce oxygen demand, it is not the first priority. Immediate actions should focus on improving oxygenation and reducing respiratory distress.

B. Obtain the client's ABG levels: Although obtaining arterial blood gases provides valuable information about oxygenation and acid-base balance, it does not address the immediate need to relieve the client's breathing difficulty and hypoxia.

C. Elevate the head of the client's bed: Elevating the head of the bed promotes lung expansion and improves oxygenation, making it the first action to reduce dyspnea and ease the client’s breathing. It is a simple, quick intervention that can stabilize the client while further assessments are conducted.

D. Prepare the client for a ventilation-perfusion scan: A V/Q scan may be indicated to diagnose conditions like pulmonary embolism, but it is a diagnostic step that follows stabilization. Immediate efforts must first focus on ensuring adequate oxygenation and respiratory support.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Apply lotion between toes: Lotion should not be applied between the toes because the moisture can promote fungal infections. Instead, lotion can be applied to the tops and bottoms of the feet to prevent dryness and cracking.

B. Use a heating pad to warm feet: Clients with diabetes often have decreased sensation in their feet and using heating pads can cause burns without them realizing it. Safer methods, like wearing warm socks, should be used to keep feet warm.

C. Apply cotton socks to feet daily: Wearing clean, dry cotton socks daily helps protect the feet, maintain warmth, and absorb moisture, reducing the risk of fungal infections and skin breakdown, which are common concerns for clients with diabetes.

D. Inspect appearance of feet weekly: Clients with diabetes should inspect their feet daily, not weekly. Daily inspection helps catch cuts, blisters, or signs of infection early to prevent serious complications such as ulcers or amputations.

A. Allergy to penicillins B. Allergy to macrolides C. Allergy to sulfonamides D. Allergy to tetracyclines

Correct Answer is B

Explanation

A. Allergy to penicillins: Penicillin allergies are important when prescribing beta-lactam antibiotics like amoxicillin, but azithromycin is not a penicillin; it belongs to the macrolide class, so this allergy is not directly relevant.

B. Allergy to macrolides: Azithromycin is a macrolide antibiotic. An allergy to macrolides must be reported immediately because administering azithromycin could trigger an allergic reaction, which could be serious or life-threatening.

C. Allergy to sulfonamides: Sulfonamide allergies are relevant when prescribing medications like sulfamethoxazole-trimethoprim, but azithromycin does not belong to the sulfonamide class.

D. Allergy to tetracyclines: Tetracyclines are a different class of antibiotics, used for infections such as acne or certain respiratory infections. An allergy to tetracyclines is not a concern when administering azithromycin.

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