Physiological Adaptation Q 167

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A patient with a history of congestive heart failure arrives at the clinic complaining of dyspnea. Which of the following actions is the first the nurse should perform?

  

     A. Ask the patient to lie down on the exam table.

     B. Draw blood for chemistry panel and arterial blood gas (ABG).

     C. Send the patient for a chest x-ray.

     D. Check blood pressure.

    

    

Correct Answer: D. Check blood pressure

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A patient with congestive heart failure and dyspnea may have pulmonary edema, which can cause severe hypertension. Therefore, taking the patient’s blood pressure should be the first action.

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Option A: Lying flat on the exam table would likely worsen the dyspnea, and the patient may not tolerate it.

Option B: Blood draws for chemistry and ABG will be required, but not prior to the blood pressure assessment.

Option C: A chest X-ray may be ordered by the physician after priority nursing care.

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