what is the priority intervention for a patient presenting with chest pain
Logo

Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam 2023

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

Correct answer: A

Rationale: The correct answer is to administer aspirin. Administering aspirin is a priority intervention for a patient presenting with chest pain because it helps reduce the risk of further clot formation and improves oxygenation. Aspirin is commonly used in the initial management of suspected cardiac chest pain. Administering nitroglycerin can follow aspirin administration to help with vasodilation. Repositioning the patient or preparing for surgery are not the primary interventions for chest pain presentation.

2. During a change-of-shift report, a nurse is receiving information about an adult female client who is postoperative. Which of the following client information should the nurse report?

Correct answer: B

Rationale: The correct answer is B because a blood pressure of 110/70 mm Hg is within the normal range and stable. Reporting this information is crucial to monitor the client's condition postoperatively. Oxygen saturation of 95% is acceptable, a temperature of 36.8°C (98.2°F) is normal, and a heart rate of 88/min is within the expected range for an adult female client, so these values do not raise concerns that require immediate reporting.

3. A nurse is assessing a client who is 1 day postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: Abdominal distention and rigidity may indicate a postoperative complication, such as bowel obstruction or peritonitis, and should be reported to the provider. While monitoring urine output, heart rate, and wound drainage are essential postoperative assessments, they are not as concerning as abdominal distention and rigidity, which could signal a more urgent issue requiring immediate attention.

4. How should fluid balance in a patient with heart failure be monitored?

Correct answer: A

Rationale: The correct answer is to monitor daily weight. Daily weight monitoring is crucial in assessing fluid balance in patients with heart failure because sudden weight gain can indicate fluid retention. Monitoring input and output (choice B) is important but may not provide a complete picture of fluid balance. Checking for edema (choice C) is a sign of fluid accumulation but may not be as accurate as daily weight monitoring. Monitoring blood pressure (choice D) is important in heart failure management but does not directly assess fluid balance.

5. A nurse is providing discharge teaching to a client who has a new prescription for enoxaparin. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct answer is to inject the medication into the abdomen. Enoxaparin should be administered subcutaneously into the abdomen for optimal absorption. Choice A is incorrect as there is no specific interaction between enoxaparin and spinach. Choice B is incorrect as massaging the injection site after administration is not recommended and can increase bruising. Choice C is incorrect as enoxaparin injections should not be administered into the deltoid muscle.

Similar Questions

A nurse is assessing a client who has just received an opioid medication. Which of the following findings should the nurse monitor first?
A nurse is caring for a client who has diabetes insipidus and is receiving desmopressin. Which of the following findings indicates the medication is effective?
A nurse is caring for a client who has a wound infection and is receiving gentamicin. Which of the following laboratory values should the nurse monitor to detect an adverse effect of this medication?
A patient is receiving chemotherapy and has developed stomatitis. Which of the following dietary recommendations should the nurse make?
A nurse is caring for a client who has a new prescription for metformin. Which of the following findings in the client's medical history should the nurse report to the provider?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses