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 B
Explanation
A. Swelling of the lower extremity can create a wound that is difficult to heal. Swelling typically relates to venous ulcers, not arterial ulcers, which are caused by reduced blood flow.
B. Decreased blood flow to the area can cause the wound and decrease the healing. Peripheral artery disease causes decreased blood flow, leading to poor oxygenation and slow healing of arterial ulcers.
C. Lower extremity compression stockings likely caused the wound to occur. Compression stockings are used in venous insufficiency and do not cause arterial ulcers.
D. Increased blood sugar associated with the condition is likely the cause of the wound not healing. While high blood sugar can impair healing, decreased blood flow is the primary cause of arterial ulcers in PAD.
Correct Answer is A
Explanation
A. Obtain a pair of slipper socks for the client. Slipper socks can provide warmth without applying direct heat, which is safer for clients with impaired circulation.
B. Increase the client's oral fluid intake. Increasing fluids does not directly address cold feet and may be contraindicated depending on the client’s condition.
C. Rub the client's feet briskly for several minutes. Rubbing can damage skin and tissue in clients with poor circulation and should be avoided.
D. Place a moist heating pad under the client's feet. Heating pads can cause burns and further impair circulation in clients with vascular issues.