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

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with chest pain because it helps relieve chest pain by dilating coronary arteries, improving blood flow to the heart muscle. Assessing pain level, monitoring vital signs, and providing oxygen therapy are important interventions as well, but administering nitroglycerin takes precedence in addressing the immediate symptom of chest pain and potential cardiac ischemia.

2. The healthcare provider is planning care for a non-potty-trained child with nephrotic syndrome. Which intervention provides the best means of determining fluid retention?

Correct answer: A

Rationale: Daily weighing is the most accurate method to monitor fluid retention in a child with nephrotic syndrome. Changes in weight can indicate fluid retention or loss, which is crucial in managing nephrotic syndrome. Observing for pitting edema and measuring abdominal girth are also important assessments, but daily weighing provides more immediate and precise information about fluid status.

3. The nurse is caring for a client with a history of deep vein thrombosis (DVT) who is receiving warfarin (Coumadin). Which laboratory value should the nurse monitor closely?

Correct answer: B

Rationale: Prothrombin time (PT) is monitored to ensure therapeutic levels of warfarin and prevent bleeding complications.

4. The client with a history of heart failure is taking furosemide (Lasix). Which laboratory result should the nurse monitor closely?

Correct answer: B

Rationale: Furosemide (Lasix) is a loop diuretic that can lead to potassium loss, causing hypokalemia. Monitoring serum potassium levels is crucial to prevent complications such as cardiac dysrhythmias associated with low potassium levels.

5. You have arrived for your shift on the children's ward and need to assess a 2-year-old who is accompanied by his father. Identify the appropriate strategy to successfully complete a focused assessment:

Correct answer: D

Rationale: Having the child sit in parent's lap can help reduce anxiety and allow for a more accurate assessment.

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