A nurse is assisting with the care of a client in the emergency department who reports severe radiating chest pain and shortness of breath. The client appears restless, frightened, and slightly cyanotic. The provider prescribes oxygen by nasal cannula at 4 L/min stat, cardiac enzyme levels, IV fluids, and a 12-lead ECG. Which of the following actions should the nurse take first?
Attach the leads for a 12-lead ECG.
Obtain a blood sample.
Initiate oxygen therapy.
Insert the IV catheter.
The Correct Answer is C
Choice A reason: While attaching leads for a 12-lead ECG is important, it is not the most immediate action required for a client showing signs of distress and potential hypoxia.
Choice B reason: Obtaining a blood sample is necessary for diagnosing the cause of chest pain but is not the first priority in an emergency situation.
Choice C reason: Initiating oxygen therapy is the first and most critical step in managing a client with severe chest pain, shortness of breath, and cyanosis to ensure adequate oxygenation.
Choice D reason: Inserting an IV catheter is important for administering medications and fluids but comes after ensuring the client is receiving sufficient oxygen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This statement is not appropriate as it may sound condescending and does not acknowledge the client's effort in a respectful manner.
Choice B reason: This question could be perceived as intrusive and might make the client feel defensive about their self-care activities.
Choice C reason: This response is appropriate as it is a neutral observation that acknowledges the client's effort without making judgments or assumptions.
Choice D reason: While this statement is positive, it may not be the best choice as it could be interpreted as patronizing rather than a simple acknowledgment.
Correct Answer is C
Explanation
Choice A reason: Gluten is not typically restricted for patients taking MAOIs unless they have a separate condition that requires this diet.
Choice B reason: Extra salt does not interact with MAOIs, so it is not necessary to avoid it unless the patient has other health concerns that require a low-sodium diet.
Choice C reason: Processed lunch meats are high in tyramine, which can cause dangerous interactions with MAOIs, leading to hypertensive crises.
Choice D reason: While caffeine may need to be limited, it is not as critical as avoiding high-tyramine foods like processed lunch meats when taking MAOIs.
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