A patient who has chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action would the nurse take first?.

Auscultate the breath sounds.

Check the capillary refill.

Auscultate the abdomen.

Ask about the patient's allergies.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

In a patient with severe dyspnea and a dry, hacking cough, auscultating the breath sounds would be the first action to assess for any abnormalities.

Choice B rationale:

Checking the capillary refill would not be the first action as it does not directly relate to the symptoms of severe dyspnea and a dry, hacking cough.

Choice C rationale:

Auscultating the abdomen would not be the first action as it does not directly relate to the symptoms of severe dyspnea and a dry, hacking cough.

Choice D rationale:

Asking about the patient’s allergies would not be the first action as it does not directly relate to the symptoms of severe dyspnea and a dry, hacking cough.

So, the correct answer is A, after analyzing all choices.

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Correct Answer is B

Explanation

Choice A rationale:

Teaching the patient to take deep, slow breaths might not be effective in controlling the pain due to acute pericarditis.

Choice B rationale:

Placing the patient in Fowler’s position, leaning forward on the table, can help relieve the pain associated with acute pericarditis.

Choice C rationale:

Forcing fluids to 3000 mL/day to decrease inflammation is not a recommended action for managing pain due to acute pericarditis.

Choice D rationale:

Providing a fresh ice bag every hour for the patient to place on the chest is not a recommended action for managing pain due to acute pericarditis.

So, the correct answer is B, after analyzing all choices.

A. "I can expect nausea as a side effect of nitroglycerin.”. B. "I will store the medication in a well-lit room.”. C. "I will call an ambulance if I have pain 5 minutes after taking nitroglycerin.”. D. "I should only take nitroglycerin when I have chest pain.”.

Correct Answer is C

Explanation

Choice A rationale:

Nitroglycerin can cause side effects such as headache and dizziness, but nausea is not a common side effect.

Choice B rationale:

Nitroglycerin should be stored in a dark, cool place, not in a well-lit room.

Choice C rationale:

This is the correct answer. If chest pain is not relieved 5 minutes after taking nitroglycerin, it is recommended to call an ambulance.

Choice D rationale:

While nitroglycerin is taken when chest pain occurs, it can also be taken prior to activities that might cause chest pain.

So, the correct answer is Choice C, after analyzing all choices.

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A patient who has chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action would the nurse take first?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has pain due to acute pericarditis. Which action would the nurse take?.

Correct Answer is B

Explanation

Which patient statement indicates that the nurse's teaching about sublingual nitroglycerin (Nitrostat) has been effective?.

Correct Answer is C

Explanation

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