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

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?

A. The client with three (3) unifocal PVCs in a minute
B. The client diagnosed with coronary artery disease who wants to ambulate
C. The client diagnosed with mitral valve prolapse with an audible S3
D. The client diagnosed with pericarditis who is in normal sinus rhythm

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. What is the combat health support system in the field designed to do?

A. Provide evacuation to the far rear for treatment and delay return to duty
B. Project, sustain, and protect the health of the soldier in war and operations other than war
C. Provide rearward evacuation and reassignment
D. Provide far rear area care and delayed return to duty

Correct answer: B

Rationale: The combat health support system in the field is primarily designed to project, sustain, and protect the health of soldiers during war and other operations. Choice A is incorrect as it focuses solely on evacuation and delaying return to duty, missing the broader scope of health support. Choice C is incorrect as it only mentions rearward evacuation and reassignment, which is not the sole purpose of the combat health support system. Choice D is also incorrect as it emphasizes far rear area care and delayed return to duty, neglecting the comprehensive nature of health support in combat situations.

3. The client is four hours post-operative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client?

A. Assist the client in ambulating
B. Assess the client's bilateral pedal pulses
C. Maintain a continuous IV heparin drip
D. Provide clear liquids to the client

Correct answer: B

Rationale: Assessing the client's bilateral pedal pulses is essential in this situation as it helps in evaluating the peripheral perfusion and circulation in the lower extremities. This assessment is crucial to detect any signs of decreased blood flow or complications, such as arterial occlusion or thrombosis. Ambulating the client may be important in the postoperative period, but assessing pedal pulses takes priority to ensure adequate perfusion. Maintaining continuous IV heparin drip is not typically indicated immediately post-operatively for an abdominal aortic aneurysm repair, as the risk of bleeding complications may outweigh the benefits. Providing a clear liquid diet is not a priority nursing intervention at this stage, as the focus should be on vascular assessment and postoperative monitoring.

4. The nurse has been assigned to train the unlicensed nursing assistant about prioritizing care. Which client should the nurse instruct the unlicensed nursing assistant to see first?

A. The client who needs both sequential compression devices removed
B. The elderly woman who needs assistance ambulating to the bathroom
C. The surgical client who needs help changing the gown after bathing
D. The male client who needs the intravenous fluid discontinued

Correct answer: A

Rationale: The correct answer is A because removing sequential compression devices could increase the risk of thromboembolism, making it the priority. Choice B involves assisting with ambulation, which can be done after addressing the urgent need of the client in choice A. Choice C and D involve non-urgent tasks compared to the potential risks associated with not removing sequential compression devices promptly.

5. What is the best way to manage a patient's intake of dietary fiber?

A. Increase intake gradually
B. Increase intake suddenly
C. Decrease intake abruptly
D. Maintain a high intake

Correct answer: A

Rationale: The correct way to manage a patient's intake of dietary fiber is to increase it gradually. This approach helps prevent gastrointestinal discomfort that can occur when fiber intake is suddenly increased. Choice B is incorrect because sudden increases in fiber intake can lead to bloating, gas, and other digestive issues. Choice C is incorrect as decreasing fiber intake abruptly can disrupt bowel regularity and cause constipation. Choice D is incorrect because maintaining a high intake of fiber without considering the patient's current levels can also cause digestive problems.