A client was admitted 2 days ago with pneumonia. The client is now having chest pain. Vital signs are Temperature 37.2 C (98.9 F), Pulse 108, Blood pressure 160/90, respirator rate 24, and Oxygen Saturation 90%. What should the nurse do first?
Call another nurse for help
Give pain medication as ordered
Call the admitting healthcare provider
Tell client to remain calm
Apply oxygen via nasal cannula as ordered
The Correct Answer is E
A. Calling another nurse for help is unnecessary unless additional assistance is required after initial interventions.
B. Giving pain medication as ordered may address the chest pain but does not address the immediate need for oxygenation.
C. Calling the admitting healthcare provider can be done later if symptoms do not improve, but the immediate priority is to improve oxygenation.
D. Telling the client to remain calm may help reduce anxiety but does not address the low oxygen saturation.
E. Applying oxygen via nasal cannula as ordered is the priority action to improve the client’s oxygen saturation and alleviate hypoxemia, which could be contributing to their chest pain.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is ["A","B","E"]
Explanation
A. Edema is a common finding in heart failure due to fluid retention.
B. Shortness of breath occurs due to fluid accumulation in the lungs, common in heart failure.
C. Increased appetite is not typical in heart failure; decreased appetite is more common.
D. Weight gain due to fluid retention is more common in heart failure, rather than extreme weight loss.
E. Jugular vein distention is a classic sign of right-sided heart failure due to increased central venous pressure.
Correct Answer is D
Explanation
A. Fluid restriction by mouth is not typically necessary with opioid administration unless other health conditions require it.
B. A low salt diet is unrelated to opioid administration unless there are concurrent health issues like hypertension or fluid retention.
C. A chest x-ray is not indicated solely due to opioid use.
D. Stool softener medication is commonly prescribed alongside opioid medications because opioids frequently cause constipation due to reduced gastrointestinal motility.
E. Antidiarrheal medication is not needed, as opioids are more likely to cause constipation rather than diarrhea.