how should a nurse respond to a patient who is exhibiting signs of acute myocardial infarction ami
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment Form A

1. How should a healthcare provider respond to a patient who is exhibiting signs of acute myocardial infarction (AMI)?

Correct answer: A

Rationale: When a patient is exhibiting signs of acute myocardial infarction (AMI), the priority action is to call for emergency assistance immediately. This ensures that the patient receives prompt and appropriate care, including interventions such as administering oxygen, nitroglycerin, and monitoring cardiac rhythm. Administering nitroglycerin should only be done if prescribed by a healthcare provider after assessment and confirmation of AMI. Monitoring the patient's cardiac rhythm is important but not the initial action needed in this critical situation. Administering oxygen and preparing for an ECG are important interventions but should follow the immediate step of calling for emergency assistance.

2. What is a key component of a comprehensive discharge plan for a patient with heart failure?

Correct answer: A

Rationale: The main components of a comprehensive discharge plan for a patient with heart failure include advising on appropriate physical activity and exercise to improve cardiovascular health and overall well-being. While fluid restriction and dietary recommendations are important aspects of heart failure management, advising on physical activity and exercise is crucial for improving cardiac function and quality of life post-discharge. Medication management is also essential but focusing on physical activity is particularly relevant for long-term management and preventing readmissions.

3. A nurse is observing a patient's use of a walker. Which observation indicates a need for further teaching?

Correct answer: A

Rationale: The correct answer is A because advancing the walker too far ahead increases the risk of falls, indicating a need for further teaching. Choice B is correct as using the walker to assist in standing is a proper use. Choice C is correct as maintaining balance while using the walker shows proper technique. Choice D is incorrect as walking with the back hunched over is a posture issue, not directly related to walker use.

4. Which intervention is most effective in preventing postoperative complications?

Correct answer: B

Rationale: The most effective intervention in preventing postoperative complications is to ambulate the patient as soon as possible. Early ambulation helps prevent complications like deep vein thrombosis and pneumonia by enhancing circulation and preventing respiratory issues. Encouraging the patient to drink fluids, perform deep breathing exercises, or range of motion exercises are beneficial interventions, but ambulation is the priority due to its overall impact on preventing various postoperative complications.

5. A client asks about becoming an organ donor. What information should the nurse provide?

Correct answer: D

Rationale: The correct answer is D. For organ donation to be legally valid, the donor must sign consent documents in the presence of a witness. Choice A is incorrect because while discussing with family is important, it is not a legal requirement for organ donation. Choice B is incorrect as the organ donation process involves various steps and procedures that cannot begin immediately. Choice C is incorrect because organ donation typically requires consent and cooperation from the family if the donor is unable to provide consent.

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