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

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?

A. Administer aspirin
B. Provide oxygen
C. Perform an ECG
D. Administer nitroglycerin

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. A staff nurse is challenging a shift assignment with the charge nurse. Which of the following statements made by the charge nurse is an example of smoothing as a strategy to resolve conflict?

A. If you accept this assignment today, I will let you choose your assignment tomorrow
B. If you don't agree with the assignment, I will have to report your decision to the nursing supervisor
C. Let's just focus on giving our client medications on time
D. You have a lot of experience, so I'm sure you're capable of these tasks

Correct answer: D

Rationale: The correct answer is D because it exemplifies smoothing as a conflict resolution strategy. Smoothing involves downplaying conflict and reassuring the individual to reduce tension. In this statement, the charge nurse acknowledges the staff nurse's experience and capability to perform the assigned tasks, which aims to reduce conflict and promote a positive outlook. Choices A, B, and C do not reflect smoothing. Choice A involves a conditional agreement, choice B introduces a threat of reporting, and choice C shifts the focus away from the conflict.

3. Which patient should the nurse see first?

A. A 1-month-old infant looking at a shiny, round battery just out of arm's reach.
B. A 56-year-old patient with oxygen and a lighter on the bedside table.
C. A 56-year-old patient with oxygen using an electric razor for grooming.
D. A bedridden patient who has a reddened area on the buttocks and needs to be turned.

Correct answer: B

Rationale: The correct answer is B because the patient with oxygen and a lighter on the bedside table is at immediate risk of fire. Oxygen promotes combustion, and having a lighter nearby poses a serious safety hazard. This situation requires urgent attention to prevent a potential disaster. Choices A, C, and D do not present immediate life-threatening risks compared to the patient with oxygen and a lighter nearby.

4. A nurse is caring for a client with pneumonia who has a new prescription for antibiotics. Which of the following actions should the nurse take first?

A. Administer the antibiotic immediately
B. Obtain a sputum culture
C. Notify the provider of the prescription
D. Check the client's allergy history

Correct answer: B

Rationale: The correct first action for the nurse to take when caring for a client with pneumonia who has a new prescription for antibiotics is to obtain a sputum culture. This is important to identify the specific bacteria causing the pneumonia before administering antibiotics. Administering the antibiotic immediately (Choice A) may not be appropriate without knowing the specific pathogen. Notifying the provider of the prescription (Choice C) is important but not the first action to be taken. Checking the client's allergy history (Choice D) is relevant but not the priority in this situation.

5. When is removal of the restraints by the nurse appropriate?

A. When medication that has been administered has taken effect
B. When no acts of aggression are observed in the hour following the release of two extremity restraints
C. When the nurse explores with the client the reasons for the angry and aggressive behavior
D. When the client apologizes and tells the nurse that it will never happen again

Correct answer: B

Rationale: The correct answer is B. The nurse can safely remove restraints once no aggressive behavior is observed after releasing two extremity restraints for an hour. Choice A is incorrect because the removal of restraints should be based on the client's behavior rather than just the effect of medication. Choice C is incorrect as exploring reasons for aggressive behavior should be done before or during the intervention, not as a condition for removing restraints. Choice D is incorrect since an apology from the client does not guarantee a change in behavior or indicate that it is safe to remove the restraints.