what is the appropriate action for a patient experiencing chest pain

ATI RN

ATI RN Exit Exam

1. What is the appropriate action for a patient experiencing chest pain?

A. Administer aspirin
B. Reposition the patient
C. Check oxygen saturation
D. Prepare for surgery

Correct answer: A

Rationale: The correct action for a patient experiencing chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation in patients with chest pain, as it has antiplatelet effects. Repositioning the patient may not address the underlying cause of the chest pain. Checking oxygen saturation is important but not the initial priority in this scenario. Surgery is not typically the first-line treatment for chest pain without further assessment and diagnostic procedures.

2. What is the priority intervention for a patient with suspected pulmonary embolism?

A. Administer oxygen
B. Administer anticoagulants
C. Administer bronchodilators
D. Reposition the patient

Correct answer: A

Rationale: Administering oxygen is the priority intervention for a patient with suspected pulmonary embolism. Maintaining adequate oxygenation is crucial in these patients to prevent hypoxemia and support oxygen delivery to tissues. Administering anticoagulants may be necessary but is not the initial priority. Administering bronchodilators is not indicated for pulmonary embolism. Repositioning the patient does not address the immediate need for oxygenation.

3. What is the most important intervention for a patient with suspected DVT?

A. Administer anticoagulants
B. Monitor oxygen levels
C. Apply compression stockings
D. Encourage ambulation

Correct answer: A

Rationale: The correct answer is to administer anticoagulants. Administering anticoagulants is crucial in the management of deep vein thrombosis (DVT) as it helps prevent the clot from growing larger or dislodging, potentially causing a life-threatening pulmonary embolism. While monitoring oxygen levels, applying compression stockings, and encouraging ambulation are important aspects of DVT management, administering anticoagulants is the most critical intervention to prevent further complications.

4. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?

A. Request a renewal of the prescription every 8 hours.
B. Check the client's peripheral pulse rate every 30 minutes.
C. Obtain a prescription for restraint within 4 hours.
D. Document the client's condition every 15 minutes.

Correct answer: C

Rationale: When caring for a client with bipolar disorder experiencing acute mania and having obtained a verbal prescription for restraints, the nurse must ensure to obtain a formal written prescription for restraint within 4 hours. This is crucial to maintain the safety and proper care of the client. Choices A, B, and D are incorrect because renewing the prescription every 8 hours, checking pulse rate every 30 minutes, and documenting the client's condition every 15 minutes do not address the immediate need for a formal restraint prescription within 4 hours to manage the client's acute mania effectively.

5. A nurse is caring for a client who is receiving enteral nutrition through a nasogastric tube. Which of the following actions should the nurse take?

A. Flush the tube with 30 mL of sterile water before each feeding
B. Administer the feeding using a large-bore syringe
C. Keep the head of the bed elevated to 15 degrees
D. Replace the feeding bag every 24 hours

Correct answer: A

Rationale: The correct action for the nurse to take is to flush the tube with 30 mL of sterile water before each feeding. This helps maintain tube patency and prevents clogs. Choice B is incorrect because enteral feedings should be administered using a gravity drip method or a pump, not through a large-bore syringe. Choice C is incorrect because the head of the bed should be elevated to at least 30 degrees to reduce the risk of aspiration. Choice D is incorrect because the feeding bag should be replaced every 24 hours to prevent bacterial contamination.