While ambulating in the hallway following an appendectomy yesterday, a client complains of chest tightness and shortness of breath. Which action should the practical nurse (PN) implement first?

Have the client sit down in the hall.

Assist the client back to the room.

Administer sublingual nitroglycerin.

Obtain a 12-lead electrocardiogram.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A: Have the client sit down in the hall.

Choice A rationale: The PN should first have the client sit down to help alleviate the client's chest tightness and shortness of breath. Sitting down allows for better lung expansion and reduces the risk of falling due to dizziness or lightheadedness. This is the most appropriate initial action in response to the client's complaint.

Choice B rationale: While assisting the client back to their room is important, the PN should first ensure that the client is sitting down to help manage their symptoms. After the client is seated and more stable, the PN can then assist them back to their room for further assessment and intervention.

Choice C rationale: Administering sublingual nitroglycerin may be appropriate if the client is experiencing cardiac-related chest pain. However, the PN should first have the client sit down and gather more information about their symptoms before administering any medications.

Choice D rationale: Obtaining a 12-lead electrocardiogram can help assess the client's cardiac status, but it is not the first action that the PN should take in this situation. Ensuring the client's safety and managing their symptoms are immediate priorities. The PN can consider obtaining an electrocardiogram after addressing the client's immediate needs and assessing their condition further.

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Correct Answer is D

Explanation

This comment shows empathy, respect, and support for the client, without being intrusive or judgmental. The PN acknowledges the client's feelings and oﬀers companionship, which can help reduce isolation and loneliness.

The other options are not correct because:

A. This comment may be perceived as coercive or dismissive of the client's feelings, as it tries to persuade the client to do something he does not want to do or enjoy.

B. This comment may be perceived as accusatory or interrogatory, as it questions the client's decision or motive for staying in his room.

C. This comment may be perceived as minimizing or invalidating the client's feelings, as it implies that the client should not be sad or that his family is doing enough for him.

A. Document the appearance of the wound as inflamed. B. Report the appearance of the dressing to the charge nurse. C. Remove the drainage device and apply a pressure dressing. D. Compress the drainage device before closing the tab. E. Clamp the drainage tubing for the next four hours.

Correct Answer is ["B","D"]

Explanation

The correct answers are Choice B and D:

Choice B: Report the appearance of the dressing to the charge nurse,

Choice D: Compress the drainage device before closing the tab.

Choice A rationale:

Documenting the appearance of the wound as inflamed is not appropriate. As a practical nurse, the immediate concern is to take action and report any concerning findings to the appropriate healthcare provider rather than just documenting it.

Choice B rationale:

Reporting the appearance of the dressing to the charge nurse is essential. The charge nurse or a more experienced healthcare provider needs to be informed of any abnormal findings or signs of infection for further evaluation and appropriate intervention.

Choice C rationale:

Removing the drainage device and applying a pressure dressing is not within the scope of practice for a practical nurse. These actions require a higher level of expertise and are typically performed by a registered nurse or healthcare provider.

Choice D rationale:

Compressing the drainage device before closing the tab is a correct action. This helps to ensure that the device is functioning properly, and there are no leaks or obstructions in the drainage system.

Choice E rationale:

Clamping the drainage tubing for the next four hours is not recommended unless specifically ordered by a healthcare provider. Clamping the drainage tubing without appropriate orders may disrupt the normal drainage process and cause complications.

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While ambulating in the hallway following an appendectomy yesterday, a client complains of chest tightness and shortness of breath. Which action should the practical nurse (PN) implement first?

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Naxlex Comprehensive Predictor Exams

A chronically depressed older male resident of a long-term care facility has become more reclusive and today refuses to leave his room. His family has moved away and are unable to visit as much as in the past. Which comment by the practical nurse (PN) is likely to be most helpful to this client?

Correct Answer is D

Explanation

The practical nurse (PN) observes a client’s initial postoperative dressing, which is saturated with serosanguinous fluid, and a drainage device that appears partially compressed. Which follow-up actions should the PN implement? (Select all that apply.).

Correct Answer is ["B","D"]

Explanation

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