what should the nurse do first when a patient is admitted with chest pain and possible acute coronary syndrome

ATI RN

ATI Capstone Medical Surgical Assessment 1 Quizlet

1. What should the healthcare provider do first when a patient is admitted with chest pain and possible acute coronary syndrome?

A. Administer sublingual nitroglycerin
B. Get IV access
C. Auscultate heart sounds
D. Obtain cardiac enzymes

Correct answer: A

Rationale: Administering sublingual nitroglycerin is the priority intervention when a patient presents with chest pain and suspected acute coronary syndrome. Nitroglycerin helps dilate blood vessels, improve blood flow to the heart, and relieve chest pain. It is crucial to address the pain and potential ischemia promptly to prevent further cardiac tissue damage. Getting IV access, auscultating heart sounds, and obtaining cardiac enzymes are important assessments and interventions, but administering nitroglycerin takes precedence in managing acute coronary syndrome.

2. What are the common manifestations of compartment syndrome?

A. Unrelieved pain, pallor, pulselessness
B. Redness and swelling
C. Fever and infection
D. Swelling and redness

Correct answer: A

Rationale: The correct manifestations of compartment syndrome are unrelieved pain, pallor, and pulselessness. These symptoms indicate compromised blood flow and neurovascular compromise, necessitating immediate medical intervention. Redness and swelling (Choice B) are more commonly associated with inflammation or infection rather than compartment syndrome. Fever and infection (Choice C) are not typical manifestations of compartment syndrome. Swelling and redness (Choice D) are general signs that can be seen in various conditions and are not specific to compartment syndrome.

3. What lab value should be prioritized for monitoring in a patient with HIV?

A. CD4 T-cell count below 180 cells/mm3
B. Hemoglobin levels
C. Serum albumin levels
D. White blood cell count

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. Monitoring CD4 T-cell count is crucial in patients with HIV as it reflects the status of their immune system. A CD4 count below 200 cells/mm3 is indicative of severe immunocompromise, necessitating close monitoring and potential intervention. Choices B, C, and D are less specific to HIV management and do not directly reflect the immune status in these patients. Hemoglobin levels are more relevant for assessing anemia, serum albumin levels for nutritional status, and white blood cell count for overall immune response, but none are as directly tied to HIV disease progression as the CD4 T-cell count.

4. A client scheduled for electromyography (EMG) will have small needle electrodes inserted into the muscles. What should the nurse include in the teaching?

A. You will receive a fixed dose of radioisotope 2 hours before the procedure.
B. Momentary flushing will occur at the beginning of the procedure.
C. You should inform your provider if you are claustrophobic.
D. You should expect insertion of small needle electrodes into the muscles.

Correct answer: D

Rationale: The correct answer is D. During an electromyography (EMG) procedure, small needle electrodes are inserted into the muscles to assess muscle weakness and nerve responses. Choices A, B, and C are incorrect because radioisotope is not used in EMG, flushing is not a typical occurrence, and claustrophobia is more relevant for imaging procedures like MRI or CT scans, not EMG.

5. What should be included in teaching for a patient with pre-dialysis end-stage kidney disease?

A. Limit phosphorus intake to 700 mg/day
B. Increase protein intake to 1g/kg/day
C. Increase sodium intake
D. Limit sodium to 1,500 mg/day

Correct answer: A

Rationale: The correct answer is to limit phosphorus intake to 700 mg/day for a patient with pre-dialysis end-stage kidney disease. Excessive phosphorus intake can lead to further complications in kidney disease, such as bone and cardiovascular issues. Choice B is incorrect as increasing protein intake can put additional stress on the kidneys due to the buildup of urea and other waste products. Choice C is incorrect because increasing sodium intake can worsen hypertension and fluid retention, common issues in kidney disease. Choice D is incorrect as limiting sodium intake is generally recommended in kidney disease to manage blood pressure and fluid balance.