what is the nurses priority intervention for a patient experiencing chest pain

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment A

1. What is the priority intervention for a patient experiencing chest pain?

A. Administer nitroglycerin as prescribed.
B. Encourage the patient to take deep breaths.
C. Monitor the patient's blood pressure closely.
D. Encourage the patient to rest in a comfortable position.

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin as prescribed. Nitroglycerin helps relieve chest pain by dilating blood vessels and improving blood flow, addressing the immediate concern of chest pain. Encouraging deep breaths may not be appropriate for chest pain, monitoring blood pressure, although important, is not the priority when the patient is experiencing chest pain, and while resting in a comfortable position is beneficial, administering nitroglycerin is the priority intervention to address the chest pain.

2. What is the primary intervention for a client diagnosed with delirium?

A. Provide a quiet and calm environment to minimize confusion
B. Administer medication to reverse the symptoms of delirium
C. Provide opportunities for social interaction to reduce isolation
D. Encourage the client to remain physically active

Correct answer: A

Rationale: The correct answer is A: Provide a quiet and calm environment to minimize confusion. For clients diagnosed with delirium, creating a tranquil setting can help reduce agitation and disorientation. This intervention aims to decrease stimuli that may exacerbate symptoms. Administering medication (choice B) is not the primary intervention for delirium; it is usually reserved for specific underlying causes. While social interaction (choice C) and physical activity (choice D) are beneficial for overall well-being, they are not the primary interventions for managing delirium.

3. During a home visit with an older adult client, a nurse should address which of the following observations to promote a safe environment?

A. Loud volume of the television set
B. Wall-to-wall carpet in the living room
C. Low chairs without armrests
D. Use of indirect lighting

Correct answer: C

Rationale: The correct answer is C: Low chairs without armrests. This observation should be addressed by the nurse to promote a safe environment for the older adult client. Low chairs without armrests increase the risk of falls as they can be challenging for older adults to sit down on or get up from. Addressing this issue can help prevent falls and promote safety. Choices A, B, and D are not as crucial for promoting a safe environment compared to the risk posed by low chairs without armrests.

4. A client with a new prescription for sumatriptan tablets to treat migraine headaches should report which of the following symptoms to the nurse?

A. Chew the tablet well before swallowing
B. Report swelling of the eyelids after dosage
C. Repeat dose in 1 hour for unrelieved headache
D. Take daily to prevent headaches

Correct answer: B

Rationale: The correct answer is B because swelling of the eyelids is a side effect of sumatriptan tablets that requires immediate reporting to the healthcare provider to prevent further complications. Choices A, C, and D are incorrect. Chewing the tablet well before swallowing is not necessary for sumatriptan tablets. Repeating the dose in 1 hour for unrelieved headache is incorrect as this medication should not be repeated within 24 hours. Taking sumatriptan daily for headache prevention is also incorrect as it is used for acute treatment, not prevention.

5. A client with left hemiparesis is learning how to use a cane. Which of the following instructions should the nurse include?

A. Place the cane approximately 61 cm (24 in) in front of their feet before advancing
B. Advance the stronger leg and the cane together to support the weaker leg
C. Remove the rubber tip when using the cane
D. Hold the cane on the right side to provide support for the weaker leg

Correct answer: D

Rationale: The correct way to use a cane for a client with left hemiparesis is to hold the cane on the right side to provide support for the weaker left leg. This allows for better stability and weight distribution. Placing the cane approximately 61 cm (24 in) in front of their feet before advancing (Choice A) is not necessary and may lead to improper gait. Advancing the stronger leg and the cane together (Choice B) is incorrect as it does not provide support for the weaker leg. Removing the rubber tip when using the cane (Choice C) is also incorrect as the rubber tip helps provide traction and stability.