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 characteristics of a thrombotic stroke?

A. Gradual onset over minutes to hours
B. Numbness on one side of the body
C. Associated with a loss of consciousness
D. Associated with seizures and convulsions

Correct answer: A

Rationale: The correct answer is A. Thrombotic strokes typically have a gradual onset over minutes to hours as they result from a clot obstructing blood flow. Choice B, numbness on one side of the body, is more commonly associated with an ischemic stroke rather than specifically a thrombotic stroke. Choice C, loss of consciousness, is not a defining characteristic of a thrombotic stroke. Choice D, seizures and convulsions, are more commonly seen in hemorrhagic strokes rather than thrombotic strokes.

3. What are the early signs of increased intracranial pressure (IICP)?

A. Restlessness, irritability, and confusion
B. Sudden onset of seizures
C. Decreased heart rate and pupillary response
D. Loss of consciousness

Correct answer: A

Rationale: The correct answer is A: Restlessness, irritability, and confusion are early signs of increased intracranial pressure (IICP). These signs indicate that the brain is starting to experience pressure, often due to conditions such as trauma, tumors, or hemorrhage. Sudden onset of seizures (choice B) is not typically an early sign of IICP but can occur later as the pressure increases. Decreased heart rate and pupillary response (choice C) are more indicative of late-stage IICP as the brainstem becomes compromised. Loss of consciousness (choice D) is a late sign of IICP when the pressure has significantly increased and is causing significant brain dysfunction.

4. What dietary modifications are recommended for a patient with pre-dialysis kidney disease?

A. Limit phosphorus intake to 700 mg/day
B. Increase sodium intake to 3 g/day
C. Restrict protein intake to 0.55-0.60 g/kg/day
D. Eat three large meals per day

Correct answer: A

Rationale: The correct answer is A: Limit phosphorus intake to 700 mg/day. Patients with pre-dialysis kidney disease should limit phosphorus intake to prevent further kidney damage. Excessive phosphorus can lead to mineral and bone disorders. Choice B is incorrect because increasing sodium intake is not recommended in pre-dialysis kidney disease. Choice C is incorrect as protein restriction is a common recommendation in advanced kidney disease, not pre-dialysis. Choice D is incorrect as eating three large meals per day is not a specific dietary modification for pre-dialysis kidney disease.

5. What should a healthcare professional do if a patient experiences abdominal cramping during enema administration?

A. Lower the height of the enema solution container
B. Stop the procedure and remove the tubing
C. Continue the enema at a slower rate
D. Increase the flow of the enema solution

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the healthcare professional should lower the height of the enema solution container. This action helps relieve the cramping by slowing down the flow of the enema solution, making it more comfortable for the patient. Stopping the procedure and removing the tubing (Choice B) may be necessary in some cases, but it should not be the first step when cramping occurs. Continuing the enema at a slower rate (Choice C) may exacerbate the cramping, so it is not the best course of action. Increasing the flow of the enema solution (Choice D) will likely worsen the cramping and should be avoided.