An emergency department nurse is collecting information from a client who has stable vital signs when their other client begins to report chest pain. Which of the following should be the nurse's priority?
Call the client's home for someone to pick up the client.
Call for a code blue.
Ask another nurse to assess the client who reports chest pain.
Alert the RN to assess the client reporting chest pain
The Correct Answer is C
A. Call the client's home for someone to pick up the client. This is not appropriate in an emergency situation. The client reporting chest pain needs immediate attention, and arranging for pick-up is not a priority.
B. Call for a code blue. Code blue is reserved for clients in cardiac or respiratory arrest. The nurse needs to assess the severity of the chest pain first before calling a code.
C. Ask another nurse to assess the client who reports chest pain. The priority is to ensure that the client reporting chest pain is assessed immediately. Delegating this task to another nurse allows prompt care for the client with potential cardiac issues while ensuring that the first client continues to receive care.
D. Alert the RN to assess the client reporting chest pain: While notifying the RN is important, it may delay the initial assessment and intervention needed for the client with chest pain. Delegating to another available nurse is a more immediate action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Emboli: Emboli can form as vegetations break off from the heart valves and travel to other parts of the body, causing complications such as stroke, pulmonary embolism, or organ infarction.
B. A heart murmur: A heart murmur is a common symptom of infective endocarditis but not a complication. It results from valve damage caused by the infection.
C. Petechiae: Petechiae are a manifestation of infective endocarditis, not a complication. They occur due to the damage to blood vessels by emboli or infection.
D. Fever: Fever is a common sign of infective endocarditis due to the ongoing infection but is not considered a complication.
Correct Answer is C
Explanation
A. Call the client's home for someone to pick up the client. This is not appropriate in an emergency situation. The client reporting chest pain needs immediate attention, and arranging for pick-up is not a priority.
B. Call for a code blue. Code blue is reserved for clients in cardiac or respiratory arrest. The nurse needs to assess the severity of the chest pain first before calling a code.
C. Ask another nurse to assess the client who reports chest pain. The priority is to ensure that the client reporting chest pain is assessed immediately. Delegating this task to another nurse allows prompt care for the client with potential cardiac issues while ensuring that the first client continues to receive care.
D. Alert the RN to assess the client reporting chest pain: While notifying the RN is important, it may delay the initial assessment and intervention needed for the client with chest pain. Delegating to another available nurse is a more immediate action.
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