NCLEX-PN

Category - Reduction of Risk

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A 69-year-old male client is complaining of chest pain after going to the bathroom. Which of the following should the nurse do initially?

Take blood pressure and pulse rate
Ask the client about the level of pain and note the location of pain
Give nitroglycerin sublingually
Call the attending physician immediately

Explanation

Answer: B - Assessment is the initial action of the nurse. Localizing the pain will indicate whether the client is having angina, pleuritic pain, or heartburn. Option A is correct, but is not the initial action. Option C comes later when the nurse has established the type of pain.

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