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 A
Explanation
A. Administering oxygen is crucial for clients with pneumonia, as it helps ensure adequate oxygenation, especially if respiratory function is compromised.
B. Allowing the client to choose when to eat does not directly impact the treatment of pneumonia.
C. Restricting family visits is generally not necessary unless infection control policies require it.
D. While rest is important, it is not as critical as maintaining oxygenation.
E. The location of the client in relation to the nurse’s station does not directly affect pneumonia treatment.
Correct Answer is B
Explanation
A. Venous insufficiency typically presents with swelling and pain that worsens with prolonged standing, not with exercise.
B. Claudication is the correct term, as it describes pain due to decreased blood flow to the muscles during exercise, often relieved by rest, which matches the patient's symptoms.
C. Muscle cramps may cause pain but are usually not consistently triggered by activity and relieved by rest.
D. Deep vein thrombosis would typically present with pain, swelling, warmth, and redness rather than exercise-induced pain relieved by rest.
E. Bruit from turbulent blood flow is an audible sound over an artery and not directly related to the type of pain described.