how should a nurse respond to a patient experiencing acute chest pain
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Nursing Elites

ATI LPN

ATI NCLEX PN Predictor Test

1. How should a healthcare provider respond to a patient experiencing acute chest pain?

Correct answer: A

Rationale: In the case of a patient experiencing acute chest pain, the initial response should include administering prescribed nitroglycerin. Nitroglycerin helps dilate blood vessels and improve blood flow to the heart, which can be beneficial in managing chest pain related to cardiac issues. Providing oxygen can also be helpful to support oxygenation. However, the priority in this scenario is to address the potential cardiac cause by administering nitroglycerin. Calling for emergency assistance is crucial if the patient's condition does not improve or deteriorates. Reassuring the patient is essential for emotional support but should not be the primary intervention in the case of acute chest pain.

2. What is the correct intervention for a patient experiencing anaphylaxis?

Correct answer: D

Rationale: In cases of anaphylaxis, all of the listed interventions are crucial for effective management. Administering epinephrine is the primary treatment to reverse the allergic reaction rapidly. Providing oxygen ensures adequate oxygenation to vital organs, and monitoring the airway is essential to prevent obstruction and maintain a clear air passage. Therefore, all three interventions are necessary in managing anaphylaxis. Choices A, B, and C are not individually sufficient to address all aspects of anaphylaxis, making the comprehensive approach of 'All of the above' the correct answer.

3. Which of the following is an early indication that a tracheostomy client requires suctioning?

Correct answer: B

Rationale: Irritability is indeed an early sign that a tracheostomy client may require suctioning. When a tracheostomy client becomes irritable, it can indicate that there is a need for suctioning to clear the airway. Bradycardia (choice A) refers to a slow heart rate and is not typically a direct indication for suctioning. Hypotension (choice C) indicates low blood pressure and is not specifically related to the need for suctioning. Decreased respiratory rate (choice D) can be a sign of respiratory distress, but irritability is a more direct and early indication of the need for suctioning in a tracheostomy client.

4. A nurse is reviewing the medical record of a client who was admitted for acute kidney injury. Which of the following laboratory values should the nurse expect to be elevated?

Correct answer: A

Rationale: Creatinine is the correct answer. In acute kidney injury, creatinine levels are expected to be elevated due to impaired renal function. Magnesium, hemoglobin, and white blood cell count are not typically elevated in acute kidney injury. Magnesium levels may be affected in kidney disease, but elevation is not a common finding in acute kidney injury.

5. A client is reinforcing teaching with a nurse about how to use an incentive spirometer. Which of the following actions by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B because inhaling deeply and slowly elevates the cylinder on the spirometer, promoting lung expansion. Choice A is incorrect as exhaling deeply before inhaling is not the correct technique for using an incentive spirometer. Choice C is incorrect as inhaling quickly through the spirometer does not promote optimal lung expansion. Choice D is incorrect as inhaling several short breaths does not facilitate the proper use of an incentive spirometer.

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