The nurse on the intermediate care unit received change-of-shift report on four clients with hypertension. Which patient should the nurse assess first?
A client with a blood pressure of 190/92 mm Hg who reports chest pain
A client with a blood pressure of 190/104 mm Hg who has sinus tachycardia
A client with a blood pressure of 178/90 mm Hg who has intermittent claudication
A client with a blood pressure of 172/98 mm Hg scheduled for a stress test
The Correct Answer is A
The nurse should assess the client with a blood pressure of 190/92 mm Hg who reports chest pain first. Chest pain can be a symptom of myocardial ischemia or a heart attack, which requires immediate attention. The combination of high blood pressure and chest pain is concerning and may indicate acute coronary syndrome. Prompt assessment and intervention are crucial to evaluate the cause of the chest pain and initiate appropriate treatment.
A client with a blood pressure of 190/104 mm Hg who has sinus tachycardia: While sinus tachycardia may indicate increased heart rate, it does not necessarily require immediate assessment unless other concerning symptoms are present. However, the nurse should address the elevated blood pressure in a timely manner.
Intermittent claudication refers to leg pain or discomfort during physical activity due to reduced blood flow. While it is important to assess and manage this symptom, it is not typically considered an urgent condition requiring immediate assessment compared to chest pain.
The client scheduled for a stress test may have elevated blood pressure, but if they are stable and not currently experiencing symptoms, they may not require immediate assessment compared to a client with chest pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Helping to position a client for a portable x-ray generally involves physically assisting the client in moving into the appropriate position or adjusting their body as needed. This task can be safely delegated to the UAP as long as they have received proper training on how to safely assist with positioning and have a clear understanding of the specific instructions provided by the radiology department.
Assisting the client to take the beta-blocker involves administering medication, which falls within the scope of nursing practice and requires the nurse's expertise in medication administration and monitoring the client's response.
Transporting the client to the intensive care unit via a stretcher involves moving the client to another unit and may require additional monitoring and coordination of care during the transfer. This task is best performed by the nurse, who can assess the client's stability, ensure appropriate documentation, and communicate effectively with the receiving unit.
Providing discharge-teaching instructions to the client going home requires the nurse to provide information about medications, wound care, follow-up appointments, and other important instructions. This task involves comprehensive education and assessment ofthe client's understanding, and is best performed by the nurse to ensure accurate and complete information is provided.
Correct Answer is A
Explanation
The nurse should teach the client that the transthoracic echocardiography is a noninvasive test and that nothing will be inserted into the client's body.
Transthoracic echocardiography is a diagnostic procedure that uses ultrasound to create images of the heart's structures and assess its function. It is a noninvasive test, meaning that it does not involve any insertion of instruments or devices into the body. Instead, a transducer is placed on the chest to obtain images of the heart.
The statement about managing pain aggressively during the procedure is not applicable to transthoracic echocardiography. It is generally a painless procedure that does not cause discomfort.
Transthoracic echocardiography primarily provides detailed images of the heart's structures and function, such as the chambers, valves, and pumping action. It does not specifically profile the heart's electrical activity, which is usually assessed using an electrocardiogram (ECG) or other specialized tests.
Regarding bed rest after the test, there is typically no need for bed rest following transthoracic echocardiography. The client can usually resume normal activities immediately after the procedure. However, the nurse should provide specific instructions based on the client's condition and any additional tests or interventions planned.
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