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 A

Explanation

A. Use a moisture barrier on the client's skin: Applying a moisture barrier cream helps protect the skin from irritation caused by constant exposure to stool and urine. It creates a protective layer that prevents breakdown, reduces friction, and maintains skin integrity in incontinent clients.

B. Clean the client's skin with soap and hot water: Using soap and hot water can strip the skin of natural oils and cause dryness or irritation, which increases the risk of breakdown. Gentle cleansing with mild soap and lukewarm water is recommended instead to preserve skin health.

C. Massage the area around the client's coccyx: Massaging bony prominences can damage fragile tissue and capillaries in older adults, increasing the risk for pressure injuries rather than preventing them. Light touch is appropriate, but firm massage should be avoided in at-risk areas.

D. Limit the client's fluid intake: Restricting fluids can lead to dehydration, concentrated urine, and an increased risk of urinary tract infections. Adequate hydration is essential to support overall health and skin resilience, even when managing incontinence.

A. Hypertension B. Muscle cramps C. Blurred vision D. Constipation

Correct Answer is B

Explanation

A. Hypertension: Hyponatremia typically leads to hypotension due to fluid shifts out of the vascular space rather than hypertension, especially if it is associated with hypovolemia. Low sodium levels can reduce blood volume and pressure, making hypertension an unlikely finding in this condition.

B. Muscle cramps: Muscle cramps are a common symptom of hyponatremia due to disrupted electrolyte balance affecting neuromuscular function. Low sodium levels impair muscle contraction and nerve signal transmission, leading to cramps, weakness, and fatigue.

C. Blurred vision: Blurred vision is not a typical manifestation of hyponatremia. While severe hyponatremia can cause neurological symptoms like confusion or seizures, visual disturbances like blurred vision are not primary signs linked to sodium imbalance.

D. Constipation: Constipation is more often associated with dehydration, immobility, or other electrolyte imbalances such as hypercalcemia. Hyponatremia primarily affects neuromuscular and central nervous system function rather than gastrointestinal motility.

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Area assessed	Findings
Neurological	Drowsy but easy to arouse
Vital Signs	Temperature 35.3°C (95.5° F) Heart rate 60/min Respiratory rate 16/min Blood pressure 90/60 mm Hg Oxygen saturation 94% (oxygen at 2 L/min via nasal cannula) Rates pain as 1 on 0/10 pain scale.
Integumentary	Skin cool and moist to touch.
Cardiopulmonary	Heart rate regular. Pedal pulse +1 bilateral. Lungs clear bilateral. Respirations even, nonlabored.
Abdomen	Abdomen soft, nondistended. Bowel sounds hypoactive in all four quadrants. 2x2 gauze with a clear transparent dressing intact to right lower and upper abdominal quadrant. Moderate amount of sanguineous drainage noted on the lower dressing

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 A

Explanation

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Correct Answer is B

Explanation

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