the nurse is caring for clients on a cardiac floor which client should the nurse assess first
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 2

1. The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first?

Correct answer: C

Rationale: The correct answer is C because an audible S3 in a client with mitral valve prolapse could indicate heart failure and requires immediate assessment. Choice A is not as urgent as an audible S3 in mitral valve prolapse. Choice B, a client with coronary artery disease wanting to ambulate, does not present an immediate concern compared to a potential heart failure indicated by an audible S3. Choice D, a client with pericarditis in normal sinus rhythm, is stable and does not require immediate attention when compared to a potential heart failure situation signified by an audible S3 in mitral valve prolapse.

2. Who is the first individual in the combat health support chain to make medically substantiated decisions based on military occupational specialty-specific medical training?

Correct answer: B

Rationale: The correct answer is 'Physician assistant.' Physician assistants are trained to make medically substantiated decisions based on their specific medical training within the combat health support chain. Choice A, 'Physician,' is incorrect as they may be involved but are not typically the first in line for such decisions as physician assistants. Choice C, 'Combat medic,' is incorrect as they usually provide immediate medical care but may not be the first to make medically substantiated decisions. Choice D, 'Combat lifesaver,' is incorrect as they are trained to provide basic life-saving interventions but may not have the specialized medical training to make complex medical decisions.

3. A nurse is reviewing the laboratory results for a client with a history of atherosclerosis and notes elevated cholesterol levels. Which statement by the client indicates the nurse should plan follow-up instruction on a low-cholesterol diet?

Correct answer: C

Rationale: The correct answer is C. Eating three eggs daily increases cholesterol intake, which could exacerbate atherosclerosis. Omega-3 supplements, cooking with canola oil, and flavoring meat with lemon juice do not significantly impact cholesterol levels compared to consuming three eggs daily. Therefore, the nurse should focus on educating the client to reduce egg consumption to improve cholesterol levels.

4. The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which data would cause the nurse to question administering the medication?

Correct answer: D

Rationale: The correct answer is D. A beta blocker should be withheld if the apical pulse is below 60, as it can further decrease the heart rate. Choice A is not a reason to question administering the medication as the blood pressure is within a normal range for a client with essential hypertension. Choice B is not directly related to the administration of a beta blocker. Choice C suggests a potential side effect of an ACE inhibitor, not a beta blocker.

5. The nurse had developed a close relationship with the family of a client who is dying. Which nursing intervention(s) are most appropriate in dealing with the family?

Correct answer: D

Rationale: When a nurse has established a close relationship with a dying client's family, it is important to offer holistic support. Encouraging family discussion of feelings allows them to express and process their emotions, accepting the family's experience of anger validates their feelings, and facilitating the use of spiritual practices identified by the family can provide comfort and solace. Therefore, all of the above interventions are crucial in dealing with the family during such a challenging time. Choices A, B, and C work together to provide comprehensive emotional and spiritual support, making option D the correct answer.

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