a nurse at a providers office receives a phone call from a client who reports unrelieved chest pain after taking a nitroglycerin nitrostat tablet 5 mi
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Nursing Elites

ATI RN

ATI Nursing Specialty

1. A nurse at a provider's office receives a phone call from a client who reports unrelieved chest pain after taking a nitroglycerin (Nitrostat) tablet 5 minutes ago. Which of the following is an appropriate response by the nurse?

Correct answer: Instruct the client to call 911.

Rationale: In this scenario, the client reporting unrelieved chest pain after taking a nitroglycerin tablet could be indicative of a serious cardiac event. Instructing the client to call 911 is the most appropriate response because immediate medical attention is necessary for chest pain that is not relieved by nitroglycerin. Telling the client to take an aspirin (Choice A) may not address the urgency of the situation, and aspirin might not be appropriate depending on the client's medical history. Having the client take another nitroglycerin tablet (Choice C) without relief could lead to overdosage. Advising the client to come to the office (Choice D) is not the best course of action when dealing with a potential cardiac emergency that requires immediate intervention.

2. A client hospitalized with deep vein thrombosis has been on IV heparin for 5 days. The provider prescribes oral warfarin (Coumadin) without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following is an appropriate nursing response?

Correct answer: The Coumadin takes several days to work, so the IV heparin will be used until the Coumadin reaches a therapeutic level.

Rationale: The correct answer is, 'The Coumadin takes several days to work, so the IV heparin will be used until the Coumadin reaches a therapeutic level.' Warfarin (Coumadin) is an oral anticoagulant that takes time to reach its full effect, typically a few days. In the meantime, IV heparin is used to provide immediate anticoagulation until the Coumadin levels become therapeutic. Option B is incorrect because discontinuing the IV heparin abruptly without reaching a therapeutic level with Coumadin can increase the risk of clot formation. Option C is incorrect because heparin and Coumadin do not work together to dissolve clots; they both have anticoagulant effects but work differently. Option D is incorrect because IV heparin does not directly increase the effects of Coumadin; they have different mechanisms of action.

3. In preparation for the discharge of a client with peripheral arterial disease (PAD), the nurse should include which of the following instructions?

Correct answer: Rest with the legs above heart level.

Rationale: Resting with the legs above heart level is important for clients with peripheral arterial disease (PAD) to promote better circulation and reduce leg pain. Applying a heating pad on a low setting can actually worsen symptoms by causing burns or increasing blood flow to the area, which is not recommended for PAD. While keeping the environment warm is generally beneficial, it is not a specific instruction for managing PAD. Antiembolic stockings are typically used for preventing blood clots in hospitalized patients and may not be directly related to managing PAD at home.

4. A nurse in a clinic is caring for a client who came to be tested for tuberculosis (TB) after a close family member tested positive. The nurse should know that which of the following is a diagnostic tool used to screen for TB?

Correct answer: Mantoux skin test

Rationale: The Mantoux skin test, also known as the tuberculin skin test, is a diagnostic tool used to screen for tuberculosis (TB). It involves injecting a small amount of tuberculin under the top layer of the skin on the forearm and then checking for a reaction within 48-72 hours. This test helps identify individuals who have been exposed to the TB bacteria. Sputum culture for acid-fast bacillus (AFB) is used to confirm TB diagnosis in individuals suspected of having active TB. The BCG vaccine is used to prevent severe forms of tuberculosis in high-risk individuals but is not a diagnostic tool. While a chest X-ray can show signs of active TB disease, it is not a primary diagnostic tool for screening purposes.

5. A nurse is preparing for the hospital admission of a client who is suspected to have active tuberculosis (TB). Which of the following precautions should the nurse plan to implement to safely care for this client?

Correct answer: The client should be placed in a private room with a special ventilation system.

Rationale: When caring for a client suspected of having active tuberculosis (TB), it is essential to place the client in a private room with a special ventilation system to prevent the spread of TB bacteria to others. Choice A is incorrect because staff and visitors should wear respiratory protection, not just gowns, masks, and gloves. Choice C is incorrect as clients with TB should not be placed in a room with other clients, as they need to be isolated to prevent transmission. Choice D is incorrect because the protocol for donning and removing personal protective equipment for clients with TB is similar to other types of isolation, focusing on proper infection control measures.

Similar Questions

A nurse in a community health center is assessing the results of the purified protein derivative (PPD) testing she performed to screen for tuberculosis (TB). She interprets which of the following results as positive for a 6-year-old client with no risk factors for TB?
A client with peripheral arterial disease (PAD) is experiencing muscle pain or cramping during physical activity that resolves with rest. Which of the following symptoms is typically the initial reason clients with PAD seek medical attention?
When caring for a client with COPD, which intervention should the nurse include in the care plan?
A client is receiving oxygen therapy via a nasal cannula. The nurse should explain that this method of oxygen delivery does which of the following?
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