what is the priority nursing intervention for a patient admitted with possible acute coronary syndrome what is the priority nursing intervention for a patient admitted with possible acute coronary syndrome
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Nursing Elites

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ATI Capstone Medical Surgical Assessment 1 Quizlet

1. What is the priority nursing intervention for a patient admitted with possible acute coronary syndrome?

Correct answer: A

Rationale: The correct answer is to administer sublingual nitroglycerin. This intervention is a priority for a patient with possible acute coronary syndrome because nitroglycerin helps vasodilate coronary arteries, increase blood flow to the heart muscle, relieve chest pain, and reduce cardiac workload. Obtaining cardiac enzymes (choice B) is important for diagnosing myocardial infarction but is not the initial priority. Getting IV access (choice C) is essential for medication administration and fluid resuscitation but is not the priority over administering nitroglycerin. Auscultating heart sounds (choice D) is a routine assessment but does not address the immediate need to relieve chest pain and improve blood flow to the heart in acute coronary syndrome.

2. A secondary immune response differs from the primary immune response in that:

Correct answer: A

Rationale: The correct answer is A. A secondary immune response is characterized by being more rapid than the primary response and results in higher antibody levels. This is because memory B cells are already present and can quickly differentiate into plasma cells upon re-exposure to the antigen. Choice B is incorrect because a secondary immune response is faster, not slower, than the primary response, and it does lead to higher antibody levels. Choice C is incorrect because a secondary response does not result in a decrease in antibodies; instead, it leads to an increase. Choice D is incorrect because a secondary immune response is not limited to hyperallergic reactions, and it results in an increase, not a decrease, in antibodies.

3. A client has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention?

Correct answer: Place the bedside table on the right side of the bed.

Rationale: In a client with left homonymous hemianopsia, there is a loss of vision on the right side of both eyes. Placing the bedside table on the right side of the bed ensures that essential items are within the client's field of vision, minimizing the risk of injury or accidents. Teaching the client to scan to the right and orienting them using the clock method may be helpful strategies, but placing the bedside table on the right side of the bed is a more direct and immediate intervention to enhance the client's safety and independence.

4. During a discussion about the nursing profession at a middle school, which of the following statements is true?

Correct answer: C

Rationale: The correct answer is C. Nurses are healthcare professionals who can independently make decisions within their defined scope of practice, providing care to patients. This autonomy allows nurses to assess, diagnose, plan, intervene, and evaluate patient care without direct supervision from physicians. Choice A is incorrect because nurses need to graduate from nursing school to earn a degree, not necessarily to obtain a license. Choice B is incorrect because while continuous education is important in nursing, it is not a defining characteristic of the profession. Choice D is incorrect because while nurses are expected to adhere to professional behaviors, it is not limited to their professional lives but extends to their personal lives as well.

5. A female patient is prescribed medroxyprogesterone acetate (Provera) for dysfunctional uterine bleeding. What should the nurse include in the patient education?

Correct answer: A

Rationale: The correct answer is A. Medroxyprogesterone acetate (Provera) can cause breakthrough bleeding or spotting, which is a common side effect of this medication. Choices B, C, and D are incorrect because weight gain, increased risk of diabetes, and increased risk of breast cancer are not commonly associated side effects of medroxyprogesterone acetate. Therefore, the nurse should focus on educating the patient about the potential for breakthrough bleeding or spotting.

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