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

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. When a patient refuses to remove their religious jewelry before surgery, what is the best response for the nurse preparing for the procedure?

Correct answer: B

Rationale: The best response for the nurse is to ask the patient for permission to secure the jewelry safely. Hospital policy typically requires jewelry to be secured or removed to prevent interference during surgery. Proceeding with the surgery without addressing the issue or taping the jewelry to the patient's body are not safe practices and can lead to complications during the procedure. Directing the patient to remove the jewelry without exploring alternative solutions is not patient-centered care and may create unnecessary tension.

3. A nurse manager assigns a task outside the scope of a nursing assistant. How should the assistant respond?

Correct answer: A

Rationale: When a task is assigned that is outside the scope of a nursing assistant, it is essential for the assistant to refuse the task and report it to the charge nurse. This ensures that tasks are appropriately delegated, maintaining patient safety and adherence to professional standards. Performing the task without reporting can lead to potential risks for the patient and legal implications. Asking another nurse to perform the task may not address the issue of improper delegation. Accepting the task but documenting it later does not resolve the immediate concern of working within the assistant's scope of practice and seeking appropriate delegation.

4. A client is being taught about which foods to include in a low fiber diet. Which statement indicates understanding?

Correct answer: C

Rationale: The correct answer is C because white rice is a low-fiber food suitable for a low-fiber diet, making it an appropriate choice. Choices A, B, and D are incorrect because fresh pear, refried beans, and bran cereal are high-fiber foods and not suitable for a low-fiber diet.

5. What is the recommended procedure for a healthcare professional to follow when applying sterile gloves?

Correct answer: D

Rationale: The correct procedure for applying sterile gloves is to do so before touching any sterile equipment or surfaces. This helps maintain the sterility of the gloves. Choices A, B, and C are incorrect because they suggest incorrect sequences that may compromise the sterility of the gloves. Using non-sterile gloves first can introduce contamination, putting on gloves before a gown can lead to contamination of the gloves during gowning, and applying gloves after donning a mask can risk contamination of the gloves from the mask.

Similar Questions

A client is about to undergo surgery and is unsure about the procedure despite signing the consent. What should the nurse do?
A healthcare provider prescribes a higher-than-usual dose of medication. What is the nurse's first action?
What intervention should the nurse implement for a patient receiving a blood transfusion?
In the context of personality disorders, what is a common characteristic of a client with Borderline Personality Disorder?
A nurse is planning preoperative care for a client who will undergo surgery. Which of the following is the priority action by the nurse?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses