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Basic Adult Health Care NCLEX Heart Questions Questions

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Question 1 of 5

A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records fi ndings from the initial assessment in the client’s chart, as shown below. At 10:30 a.m., the client complains of sharp midchest pain after having a bowel movement. What should the nurse do first?

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Correct Answer: A

Rationale: The size of the thoracic aneurysm is rather large, so the nurse should anticipate rupture. A sudden incidence of pain may indicate leakage or rupture. The blood pressure and heart rate will provide useful information in assessing for hypovolemic shock. The nurse needs more data before initiating other interventions. After assessment of vital signs, neurologic status, and pain, the nurse can then contact the physician. Administering lactated Ringer’s solution would require a physician’s order

Question 2 of 5

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Question 5 of 5

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