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.
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Correct Answer is B
Explanation
A. 3+ edema indicates moderate pitting (indentation depth of 5-7 mm and lasting 10-20 seconds).
B. 1+ edema is classified as slight pitting (indentation depth less than 2 mm that disappears rapidly, typically in less than 10 seconds), making this the correct documentation.
C. 2+ edema indicates moderate pitting (indentation depth of 3-4 mm that lasts up to 15 seconds).
D. +0 indicates no edema present at all.
E. 4+ edema indicates severe pitting (indentation depth of greater than 8 mm and lasting more than 20 seconds).
Correct Answer is E
Explanation
A. In asthma, increased airway resistance can lead to decreased fremitus due to air trapping and poor conduction of vibrations.
B. Emphysema results in hyperinflated lungs, which typically decreases tactile fremitus because of increased air in the alveoli.
C. Pneumothorax involves air in the pleural space, leading to decreased tactile fremitus as well, since air does not conduct vibrations well.
D. Acute bronchitis can cause some changes in fremitus, but it typically does not significantly increase it.
E. Pneumonia causes consolidation of lung tissue, which increases tactile fremitus due to enhanced transmission of vibrations through solidified lung tissue.