Which Action Should the Nurse Take First When a Patient

question 36

Multiple Choice

Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter?

• A) Notify the health care provider.
• B) Offer reassurance to the patient.
• C) Auscultate the patient's breath sounds.
• D) Give the prescribed PRN morphine sulfate IV.

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Definitions:

General Adaptation Syndrome

A three-stage response (alarm, resistance, exhaustion) that the body goes through when exposed to chronic stress, as proposed by Hans Selye.

Primary Appraisal

The initial evaluation process where an individual assesses the significance of a stressor to determine its potential impact.

Secondary Appraisal

The cognitive process involved in evaluating the potential impact of a stressor and determining how to cope with it.

Exhaustion Stage

The final phase of the stress response, where the body has depleted its energy resources by continually trying but failing to recover from stress.