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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Being honest is important in building a therapeutic relationship and can help the patient feel understood and respected.
Choice B reason: Developing trust is crucial for effective interventions and can encourage the patient to engage in treatment and share their feelings.
Choice C reason: Showing acceptance helps the patient feel safe and validated, which is essential in treating depression.
Choice D reason: Being judgmental is not an effective intervention as it can further alienate and discourage the patient, potentially worsening their condition.
Correct Answer is B
Explanation
Choice A reason: Informing the client about the potential use of restraints could be perceived as threatening and may not be therapeutic.
Choice B reason: Assisting the client to practice social interaction in a structured setting like a community meeting can provide a safe environment for interaction and can be part of a therapeutic plan.
Choice C reason: Escorting the client to her room could be isolating and may not address the need for social interaction, which is important for clients with bipolar disorder.
Choice D reason: Allowing the client to interact freely might not be appropriate if the behavior is disturbing others. It's important to find a balance that respects both the client's needs and those of others.
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