a client who had a myocardial infarction mi two days ago reports chest pain radiating to the left arm the nurse should take which immediate action a client who had a myocardial infarction mi two days ago reports chest pain radiating to the left arm the nurse should take which immediate action
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Nursing Elites

ATI LPN

LPN Pharmacology Assessment A

1. A client who had a myocardial infarction (MI) two days ago reports chest pain radiating to the left arm. What should the nurse do immediately?

Correct answer: B

Rationale: Obtaining an ECG is crucial in this situation because it helps in assessing for potential complications, such as a recurrent MI or ongoing ischemia. This diagnostic test provides valuable information to guide further interventions and treatment. Administering morphine, oxygen, or nitroglycerin may be necessary but obtaining an ECG takes precedence to evaluate the cardiac status and determine the appropriate course of action. Administering morphine without assessing the current cardiac status through an ECG can mask important diagnostic clues. Applying oxygen and administering nitroglycerin are supportive measures that can follow the ECG to address potential hypoxia and ischemic pain relief, respectively.

2. What is the most important intervention for a patient experiencing respiratory distress?

Correct answer: A

Rationale: Administering oxygen is crucial in managing a patient experiencing respiratory distress. Oxygen therapy helps to improve oxygen levels in the blood, supporting vital organ functions. While monitoring airway patency is important, administering oxygen takes precedence in ensuring the patient receives an adequate oxygen supply. Providing bronchodilators may be beneficial in certain respiratory conditions, but the immediate priority in distress is to address oxygenation. Calling for assistance is essential, but the immediate intervention to support the patient's respiratory function is administering oxygen.

3. The healthcare provider is assessing a newborn for signs of hypoglycemia. Which finding is consistent with hypoglycemia?

Correct answer: A

Rationale: Jitteriness is a common clinical manifestation of hypoglycemia in newborns. It is important to recognize this sign promptly as it can indicate a potentially serious condition that requires immediate attention and intervention to prevent complications.

4. A nurse is caring for a newborn with hyperbilirubinemia. Which of the following interventions should be taken during phototherapy?

Correct answer: A

Rationale: During phototherapy for a newborn with hyperbilirubinemia, it is crucial to maintain an eye mask over the newborn's eyes. The purpose of the eye mask is to protect the infant's eyes from potential damage caused by the intense light used in phototherapy. While feeding the newborn frequently and monitoring temperature are essential aspects of newborn care, they are not specific to phototherapy. Administering vitamin K is important for newborns to prevent bleeding disorders but is not directly related to phototherapy for hyperbilirubinemia.

5. What is the most prevalent dietary disaccharide?

Correct answer: C

Rationale: Sucrose is the correct answer as it is the most common disaccharide found in the diet, commonly known as table sugar. Lactose is a disaccharide found in dairy products, not as prevalent in the overall diet as sucrose. Fructose is a monosaccharide commonly found in fruits and honey, not a disaccharide. Galactose is a monosaccharide commonly found in dairy products and is not the most prevalent dietary disaccharide.

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