A nurse answers a call light and finds a client anxious, short of ...

[Marty]

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?
 
  a. Assess the client's lung sounds.
  b. Notify the Rapid Response Team.
  c. Provide reassurance to the client.
  d. Take a full set of vital signs.

Question 2

A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client? (Select all that apply.)
 
  a. Assisting with chest tube insertion
  b. Facilitating pleural fluid sampling
  c. Performing frequent respiratory assessment
  d. Providing antipyretics as needed
  e. Suctioning deeply every 4 hours

[lkoler]

Answer to Question 1

ANS: B
This client has manifestations of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority.

Answer to Question 2

ANS: A, B, C, D
The client with an empyema is often treated with chest tube insertion, which facilitates obtaining samples of the pleural fluid for analysis and re-expands the lungs. The nurse should perform frequent respiratory system assessments. Antipyretic medications are also used. Suction is only used when needed and is not done deeply to prevent tissue injury.

[Marty]

Correct answers!

[lkoler]

Great! Please up vote