what is the most appropriate action when a patient experiences chest pain

ATI RN

ATI Exit Exam RN

1. What is the most appropriate action when a patient experiences chest pain?

A. Administer aspirin
B. Administer nitroglycerin
C. Reposition the patient
D. Prepare for surgery

Correct answer: A

Rationale: Administering aspirin is the correct initial action when a patient experiences chest pain. Aspirin helps reduce the risk of clot formation and is a standard first-line treatment for chest pain related to possible cardiac issues. Administering nitroglycerin may be appropriate based on the underlying cause of chest pain, but aspirin is typically administered first. Repositioning the patient is not the primary intervention for chest pain, and preparing for surgery is not the immediate action required unless indicated by a healthcare provider after assessment.

2. A nurse is caring for a client with schizophrenia. Which of the following assessment findings should the nurse expect?

A. Decreased level of consciousness
B. Inability to identify common objects
C. Poor problem-solving ability
D. Preoccupation with somatic disturbances

Correct answer: B

Rationale: In schizophrenia, clients often display an inability to identify common objects due to cognitive impairment. This is known as associative agnosia, where individuals struggle to recognize familiar objects, faces, or sounds. Choices A, C, and D are not typically associated with schizophrenia. Decreased level of consciousness is more indicative of conditions like head trauma or drug overdose. Poor problem-solving ability may be seen in various mental health disorders but is not specific to schizophrenia. Preoccupation with somatic disturbances is more commonly seen in somatic symptom disorders or somatic delusions, not a typical finding in schizophrenia.

3. A nurse is caring for a client who is at 32 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

A. Blood pressure of 120/80 mm Hg
B. Respiratory rate of 16/min
C. 1+ protein in the urine
D. Heart rate of 88/min

Correct answer: C

Rationale: The correct answer is C. 1+ protein in the urine is indicative of worsening preeclampsia and should be reported to the provider immediately. Elevated blood pressure (choice A) is expected in preeclampsia, but a reading of 120/80 mm Hg is within the normal range. A respiratory rate of 16/min (choice B) and a heart rate of 88/min (choice D) are also within normal limits and not indicative of worsening preeclampsia.

4. What is the best position for a patient experiencing shortness of breath?

A. Supine position
B. Semi-Fowler's position
C. Trendelenburg position
D. Prone position

Correct answer: B

Rationale: The best position for a patient experiencing shortness of breath is the Semi-Fowler's position. This position promotes lung expansion and improves oxygenation by allowing the chest to expand more fully. The Supine position (lying flat on the back) may worsen breathing difficulties by reducing lung capacity. The Trendelenburg position (feet elevated higher than the head) is not recommended for patients with shortness of breath as it can increase pressure on the diaphragm and compromise breathing. The Prone position (lying face down) is also not suitable for patients experiencing shortness of breath as it may further restrict breathing.

5. A nurse is preparing to administer heparin subcutaneously to a client. Which of the following actions should the nurse take?

A. Use a 21-gauge needle for injection.
B. Inject the medication into the client's deltoid muscle.
C. Administer the medication within 5 cm (2 in) of the umbilicus.
D. Massage the injection site after administration.

Correct answer: C

Rationale: The correct action the nurse should take when preparing to administer heparin subcutaneously is to administer the medication within 5 cm (2 in) of the umbilicus. This practice ensures proper subcutaneous delivery of the medication. Choice A is incorrect because a smaller gauge needle, typically 25-26 gauge, is used for subcutaneous injections. Choice B is incorrect as heparin should not be injected into the deltoid muscle but rather into fatty tissue. Choice D is incorrect as massaging the injection site after administration can lead to tissue irritation or bruising.