Author Question: A nurse walks into a client's room and finds him having difficulty breathing and complaining of ... (Read 48 times)

Kikoku · **on:** Jul 23, 2018

A nurse walks into a client's room and finds him having difficulty breathing and complaining of chest pain. He has bradycardia and hypotension. What should the nurse do next?

A) Take vital signs again in 15 to 30 minutes.
B) Document the data and report it later.
C) Ask the client if he is anxious or afraid.
D) Report findings to the physician immediately.

Question 2

The nurse at the beginning of the shift plans to see which client first, based on the following vital signs?

A) The client age 2 years whose respiratory rate is 16 breaths/minute
B) The newborn whose axillary temperature is 98.2 F (36.8 C)
C) The client age 7 years whose pulse is 120 beats/minute
D) The client age 10 years whose blood pressure is 102/62 mmHg

bubulittle310@msn.cn · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Ans: D
The nurse should immediately report bradycardia associated with difficult breathing, changes in level of consciousness, hypotension, ECG changes, and angina (chest pain). Emergency treatment is by administering atropine intravenously to block vagal stimulation and restore normal heart rate.

Answer to Question 2

Ans: A
Normal respiratory rate for a child 1 to 3 years of age is 20 to 40 breaths/minute. Therefore, the nurse should assess the 2-year-old with a respiratory rate of 16 first, as the other clients' vital signs are within normal limits.