NCLEX-PN

Category - Reduction of Risk

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While completing the initial rounds, which of the following clients should the LPN report to the RN or physician immediately?

A client with puffy eyes and bilateral crackles in the lower border of the lungs, with a respiratory rate of 32 breaths per minute
A client with chest pain that is not relieved by rest and nitroglycerin
A client with a soaked abdominal dressing
A client who has a blood pressure of 150/100 while at rest

Explanation

Answer: B - Chest pain unrelieved by rest and nitroglycerin may indicate myocardial infarction. The client’s symptoms should be reported to the RN or physician immediately. The other options require action, but a client with chest pain is the priority of the nurse.

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