A nurse is assisting with the care of a client in the emergency department and reports severe radiating chest pain and shortness of breath. The client appears restless, frightened, and slightly cyanotic. The provider prescribes oxygen by nasal cannula at 4 L/min stat, cardiac enzyme levels, IV fluids, and a 12-lead ECG. Which of the following actions should the nurse take first?
Obtain a blood sample.
Initiate oxygen therapy.
Attach the leads for a 12-lead ECG.
Insert the IV catheter.
The Correct Answer is B
A. Obtain a blood sample. Although obtaining a blood sample is essential for cardiac enzyme levels, it is not the highest priority. Addressing oxygenation takes precedence to relieve hypoxia.
B. Initiate oxygen therapy. Oxygen is the first priority to improve oxygenation in a client showing signs of hypoxia (cyanosis, dyspnea), which can prevent further ischemic damage to the heart.
C. Attach the leads for a 12-lead ECG. While obtaining an ECG is essential for diagnosing myocardial ischemia, ensuring oxygenation is more critical in this moment.
D. Insert the IV catheter. An IV line is necessary to administer fluids and medications, but oxygenation should be prioritized first to stabilize the client.
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Correct Answer is C
Explanation
A. S3 heart sounds. An S3 sound is more indicative of heart failure rather than PVCs specifically.
B. Increase in point of maximum impulse (PMI). PMI is typically displaced in conditions like ventricular hypertrophy or heart failure, not PVCs.
C. Irregular pulsations. PVCs are extra beats that interrupt the heart’s normal rhythm, leading to irregular pulsations on palpation.
D. Bradycardia. PVCs usually occur in the context of normal or elevated heart rates rather than bradycardia.
Correct Answer is D
Explanation
A. "I will avoid crossing my legs at the knees." Crossing the legs can restrict blood flow and should be avoided in PVD.
B. "I will use a thermometer to check the temperature of my bath water." Due to reduced sensation, checking the water temperature can prevent burns.
C. "I will not go barefoot." Going barefoot increases the risk of injury or infection, especially with impaired circulation.
D. "I will wear stockings with elastic tops." Stockings with tight elastic tops can restrict blood flow, worsening symptoms in PVD.