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

ATI RN

ATI Capstone Medical Surgical Assessment 2 Quizlet

1. What should be the priority action when a patient is admitted with chest pain from acute coronary syndrome?

A. Administer sublingual nitroglycerin
B. Obtain IV access
C. Check cardiac enzymes
D. Administer aspirin

Correct answer: A

Rationale: The correct answer is to administer sublingual nitroglycerin. This is the priority action in treating chest pain associated with acute coronary syndrome as it helps to dilate blood vessels, improve blood flow to the heart, and reduce cardiac tissue damage. Administering nitroglycerin is crucial in managing the symptoms and potential complications of acute coronary syndrome. Obtaining IV access (Choice B) is important for administering medications and fluids but does not address the immediate symptom of chest pain. Checking cardiac enzymes (Choice C) and administering aspirin (Choice D) are essential steps in the management of acute coronary syndrome, but they should follow the administration of nitroglycerin to address the immediate symptom and improve blood flow to the heart.

2. What dietary recommendations should be provided to a patient with GERD?

A. Avoid mint and spicy foods
B. Eat large meals before bed
C. Consume liquids with meals
D. Avoid foods high in potassium

Correct answer: A

Rationale: The correct recommendation for a patient with GERD is to avoid mint and spicy foods. These types of foods can trigger acid reflux and worsen GERD symptoms. Choice B is incorrect as eating large meals before bed can increase the likelihood of acid reflux due to increased pressure on the lower esophageal sphincter. Choice C is also incorrect as consuming liquids with meals can cause distension in the stomach, potentially leading to reflux. Choice D is not directly related to GERD, as foods high in potassium are generally healthy and not specifically problematic for GERD patients.

3. What is the purpose of an escharotomy?

A. To relieve pressure and improve circulation in burn injuries
B. To reduce pain in the affected area
C. To remove necrotic tissue from a wound
D. To prevent infection from spreading

Correct answer: A

Rationale: An escharotomy is performed to relieve pressure and improve circulation in areas affected by deep burns. This procedure helps prevent complications such as compartment syndrome by releasing the constricting eschar. Choice B is incorrect because while pain relief may be a secondary outcome of the procedure, the primary purpose is to address pressure and circulation issues. Choice C is incorrect as an escharotomy specifically focuses on releasing pressure, not removing necrotic tissue. Choice D is incorrect as the primary goal of an escharotomy is not to prevent infection but rather to address the immediate issues related to deep burn injuries.

4. A client has a Transient Ischemic Attack (TIA). What should the nurse teach?

A. Avoid eating within 3 hours of bedtime
B. Consume liquids between meals
C. Eat large meals to increase caloric intake
D. Avoid liquids to prevent aspiration

Correct answer: A

Rationale: The correct answer is A: Avoid eating within 3 hours of bedtime. For a client with a Transient Ischemic Attack (TIA), it is crucial to avoid eating within 3 hours of bedtime to reduce reflux that can worsen symptoms. Choice B is incorrect because consuming liquids between meals is not specifically related to managing TIA. Choice C is incorrect as eating large meals may not be recommended, especially if the client needs to watch their caloric intake. Choice D is incorrect because avoiding liquids entirely can lead to dehydration and is not a standard recommendation for TIA management.

5. What is the priority action if a patient experiences hypoglycemia after an insulin dose?

A. Check the patient's blood glucose level
B. Administer IV dextrose
C. Document the incident
D. Continue monitoring the patient

Correct answer: A

Rationale: The priority action when a patient experiences hypoglycemia after an insulin dose is to check the patient's blood glucose level. This is crucial to confirm hypoglycemia before initiating any treatment. While administering IV dextrose may be necessary if the patient's blood glucose level is critically low, confirming hypoglycemia is essential to guide appropriate interventions. Documenting the incident is important for documentation purposes but is not the immediate priority when the patient's safety is at risk. Continuing to monitor the patient is essential, but it should follow the confirmation and initial management of hypoglycemia.