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Free NCLEX-RN Exam Braindumps (page: 170)

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A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain. She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the client's nursing assessment demand immediate nursing action?

  1. Associated symptoms of indigestion and nausea
  2. Restlessness and apprehensiveness
  3. Inability to tolerate assessment session with the admitting nurse
  4. History of hypertension treated with pharmacological therapy

Answer(s): B

Explanation:

(A) Indigestion or nausea may accompany angina or myocardial infarction, but they do not indicate imminent danger for the client. (B) Restlessness and apprehensiveness require immediate nursing action because they are indicative of very low oxygenation of body tissues and are frequently the first indication of impending cardiac or respiratory arrest. (C) It is common for the cardiac client to experience fatigue and inability to physically tolerate long assessment sessions. (D) A history of hypertension requires no immediate nursing intervention. In the situation described, the blood pressure is not given and therefore cannot be assumed to be elevated.



A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain. She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the client's nursing assessment demand immediate nursing action?

  1. Associated symptoms of indigestion and nausea
  2. Restlessness and apprehensiveness
  3. Inability to tolerate assessment session with the admitting nurse
  4. History of hypertension treated with pharmacological therapy

Answer(s): B

Explanation:

(A) Indigestion or nausea may accompany angina or myocardial infarction, but they do not indicate imminent danger for the client. (B) Restlessness and apprehensiveness require immediate nursing action because they are indicative of very low oxygenation of body tissues and are frequently the first indication of impending cardiac or respiratory arrest. (C) It is common for the cardiac client to experience fatigue and inability to physically tolerate long assessment sessions. (D) A history of hypertension requires no immediate nursing intervention. In the situation described, the blood pressure is not given and therefore cannot be assumed to be elevated.



A client's behavior is annoying other clients on the unit. He is meddling with their belongings and dominating the group. The best approach by the nurse is to:

  1. Seclude him in his room.
  2. Set limits on his behavior.
  3. Have his medication increased.
  4. Ignore him and tell the other clients that these behaviors are due to his illness and that they should understand.

Answer(s): B

Explanation:

(A) This action by the nurse would be punitive. (B) Consistent limit setting will help the client to know what is acceptable behavior. (C) This action is not within the nurse's scope of practice. (D) This could be dangerous to the client and to others and violates other clients' rights.



A client's behavior is annoying other clients on the unit. He is meddling with their belongings and dominating the group. The best approach by the nurse is to:

  1. Seclude him in his room.
  2. Set limits on his behavior.
  3. Have his medication increased.
  4. Ignore him and tell the other clients that these behaviors are due to his illness and that they should understand.

Answer(s): B

Explanation:

(A) This action by the nurse would be punitive. (B) Consistent limit setting will help the client to know what is acceptable behavior. (C) This action is not within the nurse's scope of practice. (D) This could be dangerous to the client and to others and violates other clients' rights.






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