Question

Which of the following actions should the ambulatory care nurse implement for a client who presents tot he clinic with chest pain?

A. Refer the client immediately to the ER
B. Take vital signs and obtain ECG
C. Take detailed history
D. Call the EMS for transport

Answer 1

The ambulatory care nurse should take vital signs, obtain an ECG, and take a detailed history of a client who presents with chest pain. If necessary, they should refer the client immediately to the ER. Options A, B, and C.

Step-by-step explanation:

The ambulatory care nurse should implement the following actions for a client who presents to the clinic with chest pain:

1. Take vital signs and obtain an ECG: This will help assess the client's current condition and provide important information about their heart.
2. Take a detailed history: Gathering information about the client's symptoms, medical history, and any potential risk factors will help in making an accurate diagnosis.
3. Refer the client immediately to the ER if necessary: If the client's symptoms indicate a potential cardiac event, such as an acute myocardial infarction (MI), it is crucial to prioritize their care and transfer them to the emergency room for further evaluation and treatment.

Based on the client's symptoms, including chest pain, potential risk factors like age, and existing medical conditions, it is important to evaluate their condition thoroughly and respond accordingly.

Hence, the right answer is options A, B, and C.