How it Works
Try Naxlex NCLEX-RN (Free-Trial)

Complete the following sentence by choosing from the list of option. A nurse is caring for a client who reports anxiety, chest tightness, and no appetite.

The nurse should first assess the client's

then their , and then their

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A","dropdown-group-3":"C"}

Rationale:

  • Chest tightness is correct for Blank 1 because this symptom may indicate a potentially life-threatening condition such as cardiac or respiratory compromise. Using the ABC priority framework, physiological stability and possible airway, breathing, or circulation issues must be addressed first.
  • Anxiety is correct for Blank 2 because once immediate physiological threats are assessed, psychological distress should be evaluated. Anxiety can contribute to physical symptoms and may worsen chest discomfort.
  • No appetite is correct for Blank 3 because while important, it is not an immediate threat to physiological stability. Appetite changes can be addressed after ruling out serious causes of chest tightness and evaluating anxiety.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is A

Explanation

Rationale:

A. Suctioning the tracheostomy is the correct action. Frequent coughing and increased shortness of breath in a client with a tracheostomy commonly indicate airway obstruction from accumulated secretions. Clients with tracheostomies are unable to clear secretions effectively because the upper airway is bypassed. Suctioning helps remove mucus, restore airway patency, improve ventilation, and relieve respiratory distress. This is the priority intervention because airway clearance is essential.

B. Administering a bronchodilator may be appropriate if bronchospasm is present, but the symptoms described are more consistent with retained secretions rather than airway constriction. The nurse should first ensure the airway is clear before considering medication.

C. Administering a cough drop is inappropriate. A client with a tracheostomy does not breathe through the mouth and throat in the usual way, so a cough drop would not address airway obstruction or shortness of breath.

D. Decreasing the client's oxygen flow is unsafe and contraindicated. The client is already experiencing respiratory distress, and reducing oxygen could worsen hypoxia.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B","dropdown-group-3":"A","dropdown-group-4":"D"}

Explanation

Rationale:

  • Intramuscular injection is correctly matched with the vastus lateralis because this large muscle is commonly used for IM injections due to its size and good blood supply.
  • Intradermal injection is correctly matched with under the epidermis in the forearm because intradermal injections are administered just beneath the epidermis, typically on the inner forearm for tests such as tuberculosis screening.
  • Subcutaneous injection is correctly matched with the umbilical region of the abdomen because subcutaneous injections are given into the fatty tissue beneath the dermis, and the abdomen is a common site for medications such as insulin and heparin.
  • Intravenous injection is correctly matched with the antecubital vein because IV injections are administered directly into a vein, and the antecubital area is a commonly used site for venous access.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register