Which initial intervention is most appropriate for a patient who has a new onset of chest pain?

a. Reassess the patient.
b. Notify the health care provider.
c. Administer a prn medication for pain.
d. Call radiology for a portable chest x-ray.


ANS: A
Preparation for implementation ensures efficient, safe, and effective nursing care; the first activity is reassessment. The cause of the patient's chest pain is unknown, so the patient needs to be reassessed before pain medication is administered or a chest x-ray is obtained. The nurse then notifies the patient's health care provider of the patient's current condition in anticipation of receiving further orders. The patient's chest pain could be due to muscular injury or a pulmonary issue. The nurse needs to reassess first.

Nursing

You might also like to view...

A group of children on one hospital unit are all suffering separation anxiety. When determining the stages of separation anxiety, the nurse recognizes that the child in the "despair" phase is the child who:

1. Does not cry if his parents return and leave again. 2. Screams and cries when his parents leave. 3. Appears to be happy and content with staff. 4. Lies quietly in bed.

Nursing

When a nurse is unsure if the client has understood a teaching or message, which of these actions should be taken?

a. Ask the client if the message is understood. b. Ask the client to repeat or demonstrate the process. c. Document the teaching session. d. Reteach the concept.

Nursing

The nurse is caring for a thin, elderly client who was diagnosed with cancer and is receiving aggressive chemotherapy. The client is experiencing acute side effects and has lost 10 pounds in the past week

The nurse teaches the client to: (Select all that apply) 1. Drink liquid supplements to increase intake of nutrients. 2. Eat more warm foods and avoid cold foods. 3. Keep a food diary and record intake. 4. Eat small frequent meals high in calories. 5. Purchase fast foods and prepared foods.

Nursing

A client asks, "Can you explain to us how to use the basal body temperature method to detect ovulation and prevent pregnancy?" What would be the best reply by the nurse?

A. "Take your temperature every evening at the same time and keep a record for a period of several weeks. A noticeable drop in temperature indicates that ovulation has occurred." B. "Take your temperature every day at the same time and keep a record of the findings. A noticeable rise in temperature indicates ovulation." C. "Take your temperature each day, immediately upon awakening, and keep a record of each finding. A noticeable drop in temperature indicates that ovulation is about to occur." D. "This is an unscientific and unproven method of determining ovulation and is not recognized as a means of birth control."

Nursing