a nurse is caring for a client post myocardial infarction mi what is the priority assessment for this client
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam

1. A nurse is caring for a client post-myocardial infarction (MI). What is the priority assessment for this client?

Correct answer: C

Rationale: Assessing for chest pain is crucial in post-MI clients as it can indicate complications such as reinfarction or ischemia.

2. A client is scheduled for a colonoscopy and receiving education from a healthcare provider. Which statement by the client indicates a need for further teaching?

Correct answer: D

Rationale: The correct answer is D because clients are typically instructed to avoid solid foods for 12-24 hours before a colonoscopy, not a full 24 hours. This statement indicates a need for further teaching to ensure the client follows the correct dietary instructions for the procedure.

3. When teaching a group of clients about emergency care for a snake bite, which of the following information should the nurse include?

Correct answer: B

Rationale: In cases of snake bites, it is essential to immobilize the affected extremity with a splint to prevent the spread of venom throughout the body. Raising the extremity above the heart level can promote venom spread, and applying ice or a tourniquet can worsen the condition. Immobilization helps reduce movement and slows the circulation of venom, aiding in the prevention of further complications.

4. A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the client's blood pressure is much higher than previous readings & the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome?

Correct answer: C

Rationale: The most likely action by the nurse that would have prevented the negative outcome is providing more appropriate supervision of the UAP. Supervision is essential in delegation as it involves directing, evaluating, and following up on delegated tasks. By providing adequate supervision, the nurse can ensure that tasks are performed correctly and promptly identify any issues or abnormalities, such as a significant change in vital signs or the client's mental status. This proactive approach can help prevent adverse outcomes and enhance patient safety.

5. During an assessment of the respiratory pattern of an older adult client receiving end-of-life care, which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?

Correct answer: A

Rationale: Cheyne-Stokes respirations are characterized by a pattern of breathing that ranges from very deep to very shallow with periods of apnea (temporary cessation of breathing). This pattern is often seen in clients near the end of life or with certain medical conditions affecting the respiratory control center in the brain. The alternating deep and shallow breaths can be distressing for both the client and caregivers. It is crucial for the nurse to recognize this pattern to provide appropriate care and support to the client and their family during this challenging time.

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