a client with a history of hypertension and hyperlipidemia is admitted with chest pain what is the nurses priority action
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Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Quizlet Capstone

1. A client with a history of hypertension and hyperlipidemia is admitted with chest pain. What is the nurse's priority action?

Correct answer: B

Rationale: The correct answer is to obtain a 12-lead electrocardiogram (ECG). This action is crucial in assessing the heart's electrical activity and helps in the evaluation of chest pain. Administering nitroglycerin (Choice A) may be necessary but should come after obtaining the ECG to confirm the diagnosis. Checking vital signs (Choice C) is important but does not provide direct information about the heart's electrical status. Placing the client on continuous telemetry (Choice D) may be appropriate later but does not provide immediate information on the heart's electrical activity as an ECG does.

2. The nurse is caring for a client with deep vein thrombosis (DVT) who is receiving heparin therapy. Which assessment finding requires immediate intervention by the nurse?

Correct answer: D

Rationale: Hematuria is a sign of bleeding, which is a potential complication of heparin therapy. Immediate intervention is required to manage the bleeding and adjust the heparin dosage if necessary. Localized warmth, calf pain, and swelling in the affected leg are common findings in clients with DVT and receiving heparin therapy. While these symptoms should be monitored, hematuria indicates a more serious issue requiring immediate attention.

3. An older client with a long history of coronary artery disease, HTN, and HF arrives in the ED in respiratory distress. The healthcare provider prescribes furosemide IV. Which therapeutic response to furosemide should the nurse expect in the client with acute HF?

Correct answer: D

Rationale: The correct answer is D: Reduced preload. Furosemide is a diuretic that reduces fluid overload in heart failure, which lowers the preload (the volume of blood in the ventricles before contraction). By reducing this volume, furosemide improves symptoms of heart failure. While furosemide may lead to increased urine output and lower blood pressure, these effects are secondary to the reduction in preload. Decreased heart rate is not a direct effect of furosemide in heart failure.

4. A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse?

Correct answer: B

Rationale: In this scenario, it is more appropriate to assign a stable client, such as the one with a myocardial infarction who is free from pain and dysrhythmias, to a nurse who lacks specialized critical care experience. This client's condition is relatively stable and does not require immediate critical interventions. Choices A, C, and D involve clients with more complex and critical conditions that would be better managed by a nurse with specialized critical care training. Choice A involves a client on a Dopamine drip with frequent vital sign monitoring, Choice C has a client with a tracheotomy in respiratory distress, and Choice D describes a client with a pacemaker experiencing intermittent capture, all of which require a higher level of critical care expertise.

5. A client on long-term corticosteroid therapy for rheumatoid arthritis presents with weakness and hypotension. What is the nurse's first action?

Correct answer: A

Rationale: Administering a PRN dose of corticosteroids is the correct first action when a client on long-term corticosteroid therapy presents with weakness and hypotension. In this scenario, the client is likely experiencing adrenal insufficiency due to prolonged corticosteroid use. Administering corticosteroids promptly can help correct this insufficiency and improve the client's symptoms. Placing the client in a supine position may be necessary for symptomatic hypotension, but addressing the root cause with corticosteroids is more crucial initially. Encouraging oral fluid intake is important for many conditions but is not the priority in this case. Reviewing the client's recent medication history can provide valuable information but is not the first action needed to address the client's current presentation.

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