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 C

Explanation

A. "I do not need to sign a consent form before this procedure.": A signed informed consent form is required before an intravenous pyelogram (IVP) because it involves the injection of contrast dye, which carries risks such as allergic reactions and kidney injury.

B. "I should limit my fluid intake for 2 days after the procedure.": Clients are encouraged to increase fluid intake after an IVP to help flush the contrast dye from their system and reduce the risk of kidney complications, not limit fluids.

C. "I will feel a warming sensation after the injection of the dye.": This statement shows understanding. It is common to feel a warm, flushing sensation or a metallic taste in the mouth shortly after the contrast dye is injected during an IVP. These effects are usually brief and harmless.

D. "I can have a meal up to 2 hours before the procedure.": Clients are typically instructed to be NPO (nothing by mouth) for a certain period, often after midnight, before the procedure to reduce the risk of aspiration and to ensure clear imaging. Eating close to the procedure time is not recommended.

A. Monitor the client for 1 hr after meals B. Allow the client 2 hrs to finish meals. C. Weigh the client every 2 days. D. Check the client's vital signs two times per week.

Correct Answer is A

Explanation

A. Monitor the client for 1 hr after meals: Clients with anorexia nervosa are at high risk for purging behaviors such as vomiting or excessive exercise after meals. Monitoring them for at least 1 hour post-meal helps prevent these behaviors and supports the therapeutic goal of safe weight restoration.

B. Allow the client 2 hr to finish meals: Allowing 2 hours to complete meals is too long and may encourage food avoidance behaviors. Structured meal times with limits (usually around 30 to 45 minutes) are important to establish routine eating habits and prevent manipulation of eating times.

C. Weigh the client every 2 days: Clients with anorexia nervosa are typically weighed daily, often at the same time each morning, to closely monitor weight trends and assess the effectiveness of the treatment plan. Monitoring every 2 days may miss rapid changes that require immediate intervention.

D. Check the client's vital signs two times per week: Vital signs should be checked daily in clients with anorexia nervosa, especially early in treatment, because of the risks of bradycardia, hypotension, and hypothermia. Infrequent monitoring can delay recognition of life-threatening physiological instability.

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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

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