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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Correct Answer is B

Explanation

A. Anuria: Anuria, or the absence of urine output, indicates severe dehydration or acute renal failure rather than moderate dehydration. Moderate dehydration usually presents with decreased but not absent urine output, as the body still tries to conserve fluids.

B. A 7% weight loss from baseline: A weight loss of 6% to 9% of body weight is consistent with moderate dehydration in infants and children. This measurable sign is a critical and objective indicator used to assess the severity of dehydration, particularly following prolonged vomiting or diarrhea.

C. Hyperpnea: Hyperpnea, or abnormally deep and rapid breathing, can be seen in cases of severe dehydration or metabolic acidosis. It is not a classic finding of moderate dehydration, where respiratory patterns are usually normal or only mildly affected.

D. Lethargy: Lethargy typically suggests severe dehydration rather than moderate. In moderate dehydration, the infant may be irritable or thirsty but usually maintains normal mental status without profound decreases in responsiveness or alertness.

A. The restraint is attached to the side rails of the bed. B. The restraint the strap is tied into a knot. C. The nurse can insert two fingers under the restraint. D. The skin under the restraint is cool and has changed color.

Correct Answer is C

Explanation

A. The restraint is attached to the side rails of the bed: Restraints should never be attached to the side rails because moving the rails could cause injury to the client. Restraints must be secured to a stationary part of the bed frame to prevent tightening, which could lead to impaired circulation or nerve damage if the bed position changes.

B. The restraint strap is tied into a knot: Tying the restraint strap into a knot is unsafe because knots are difficult to untie quickly in an emergency. Quick-release ties or slipknots are recommended to ensure the client can be released rapidly if needed, reducing the risk of injury or complications from prolonged restraint.

C. The nurse can insert two fingers under the restraint: Being able to insert two fingers under the restraint indicates that it is properly applied—not too tight to impair circulation, and not too loose to be ineffective. This ensures client safety by allowing adequate blood flow and reducing the risk of skin breakdown or nerve injury.

D. The skin under the restraint is cool and has changed color: Coolness and discoloration under a restraint are signs of impaired circulation and require immediate intervention. These findings are abnormal and suggest that the restraint is too tight, potentially leading to tissue ischemia, nerve damage, or pressure injuries if not promptly addressed.

View Question and Answer

A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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