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    PN Comprehensive Predictor 2023 Proctored Exam

    A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of the following actions should the nurse take first?

    Explanation & Rationale

    A. Place the client on bedrest: While limiting activity can prevent further strain, simply placing the client on bedrest does not immediately address airway compromise or improve oxygenation. Immediate interventions to relieve dyspnea take priority. B. Obtain the client's ABG levels: Arterial blood gases provide valuable information about oxygenation and acid-base status, but drawing labs does not relieve acute respiratory distress. Assessment and interventions that improve breathing should come first. C. Elevate the head of the client's bed: Elevating the head of the bed improves lung expansion, promotes oxygenation, and reduces the work of breathing. This is a primary, noninvasive intervention that directly addresses the client’s acute symptoms and should be implemented immediately. D. Prepare the client for a ventilation perfusion scan: A V/Q scan helps diagnose pulmonary embolism but is a diagnostic measure. Diagnostic preparation does not take priority over interventions that relieve acute hypoxia and respiratory distress.

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