a client is experiencing chest pain which action should the nurse take first
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

1. A client is experiencing chest pain. Which action should the nurse take first?

Correct answer: D

Rationale: Administering nitroglycerin is the priority action when a client is experiencing chest pain as it helps alleviate the pain caused by reduced blood flow to the heart. Oxygen can be beneficial, but nitroglycerin takes precedence in this situation. Aspirin can also be given, but nitroglycerin is the priority. Performing an ECG can provide valuable information but is not the first action to take in this scenario.

2. What is the definition of malpractice in the context of professional negligence?

Correct answer: B

Rationale: The correct definition of malpractice in the context of professional negligence is the failure to act in a reasonable and prudent manner by a professional. This choice is correct because malpractice occurs when a professional does not meet the standard of care expected in their field, leading to harm or injury to the client. Choices A, C, and D are incorrect because malpractice is specifically about the failure to meet professional standards of care, rather than personal standards, miscommunication within a healthcare team, or inadequate documentation of patient care.

3. A public health nurse is developing guidelines for the management of a botulism outbreak. Which of the following information should the nurse include?

Correct answer: D

Rationale: The correct answer is D. Rinsing the skin with soap and water following exposure to the botulism toxin is crucial as it helps remove the toxin from the skin, preventing further absorption. Choices A, B, and C are incorrect. Immunoglobulin E (IgE) is not used in the management of botulism. Airborne precautions are not necessary for botulism as it is not transmitted through the air. Aminoglycoside medications are not the treatment of choice for botulism.

4. A client with a history of seizures is admitted for monitoring. What should the nurse prioritize?

Correct answer: A

Rationale: The correct answer is to ensure the client is on seizure precautions. This is crucial in preventing injury during a seizure episode. While educating the client about seizure triggers (choice B) is important for long-term management, it is not the priority when the client is admitted for monitoring. Monitoring for signs of an impending seizure (choice C) is essential but does not address immediate safety concerns. Initiating IV access for anti-seizure medication (choice D) is not the priority unless a seizure occurs and medical intervention is needed.

5. Which goal is most appropriate for a patient who has had a total hip replacement?

Correct answer: B

Rationale: Choice B is the most appropriate goal for a patient who has had a total hip replacement because it is specific, measurable, and achievable. Walking 100 feet using a walker is a realistic and individualized target for a patient in the recovery phase following hip surgery. Choices A, C, and D are not as suitable: Choice A does not specify a measurable distance or objective, Choice C sets a potentially unrealistic expectation for brisk ambulation on a treadmill, and Choice D lacks the specificity of the distance to be walked.

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