a nurse is assessing a client who has a history of angina and reports substernal chest pain that radiates to the left arm which of the following actio
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ATI RN

ATI RN Exit Exam Test Bank

1. A client with a history of angina reports substernal chest pain that radiates to the left arm. Which of the following actions should the nurse take first?

Correct answer: D

Rationale: In a client with a history of angina experiencing chest pain radiating to the left arm, obtaining a 12-lead ECG is the priority action to assess for myocardial infarction. An ECG helps in diagnosing and evaluating the extent of cardiac ischemia or infarction. Administering nitroglycerin, oxygen, or aspirin can follow once the ECG has been performed to confirm the diagnosis and guide further interventions. Administering nitroglycerin sublingually is often appropriate for angina but should not precede the ECG in this urgent scenario. Oxygen therapy and aspirin administration are important interventions but obtaining the ECG takes precedence in assessing for acute cardiac events.

2. A nurse in an emergency department is caring for a client who reports cocaine use 1hr ago. Which of the following findings should the nurse expect?

Correct answer: D

Rationale: The correct answer is D: Elevated temperature. Cocaine is a stimulant drug that can lead to an increase in body temperature. Hypotension (choice A) is less likely as cocaine tends to increase blood pressure. Memory loss (choice B) and slurred speech (choice C) are not typically immediate effects of recent cocaine use.

3. A client is 1 day postoperative following abdominal surgery. Which of the following actions should the nurse take to prevent respiratory complications?

Correct answer: B

Rationale: Encouraging the use of an incentive spirometer is crucial for preventing respiratory complications postoperatively, such as atelectasis. Instructing the client to avoid deep breathing exercises (choice A) is incorrect as deep breathing exercises help prevent respiratory complications. Assisting with ambulation every 2 hours (choice C) is important for preventing other postoperative complications but not specifically respiratory ones. Applying sequential compression devices (SCDs) (choice D) is beneficial for preventing deep vein thrombosis but not directly related to respiratory complications.

4. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse is to insert the catheter until urine flow is established. This helps ensure proper placement and reduces the risk of trauma. Choice A (7.5 cm) and Choice D (5 cm) provide specific measurements that may not be appropriate for all individuals as catheter insertion depth can vary. Choice C is incorrect as catheters should be cleansed with an appropriate solution such as sterile saline, not sterile water.

5. A nurse is assessing a client who is postoperative following a total knee arthroplasty. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: The correct answer is D. Warmth and redness in the calf are indicative of a possible deep vein thrombosis (DVT), a serious complication post-surgery that requires immediate attention. Reporting this finding promptly to the provider is crucial for timely intervention. Choices A, B, and C are within normal limits for a postoperative client and do not indicate a potentially life-threatening condition like DVT.

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