Free NCLEX RN Practice Test Practice Question
A 78-year-old client with a history of diabetes mellitus type 2, GERD, and hypertension is hospitalized with pneumonia and rings the call bell at 11 PM, complaining of being unable to sleep and having 'indigestion' and 'heartburn.' Which of the following initial interventions is most indicated?
Correct Answer: D
Rationale: Assessing cardiac and respiratory status is crucial in this scenario, as the client’s symptoms of indigestion and heartburn could indicate potential cardiac issues, especially given their age and medical history. A thorough assessment allows for the identification of any serious complications, such as myocardial infarction, which can present with similar symptoms.
Administering an antacid (Option A) may provide temporary relief but does not address the underlying cause of the symptoms. Acetaminophen (Option B) is inappropriate as it treats pain or fever, not the symptoms presented. Administering a hypnotic (Option C) could worsen the situation by masking serious symptoms, delaying necessary interventions. Prioritizing assessment ensures patient safety and appropriate care.
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