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 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 client with a new prescription for furosemide should increase intake of which of the following?

Correct answer: B

Rationale: The correct answer is B: 'You should increase your intake of potassium-rich foods.' Furosemide is a potassium-wasting diuretic, which means it can lead to low potassium levels in the body. Increasing intake of potassium-rich foods helps counteract this effect. Choices A, C, and D are incorrect because furosemide should not necessarily be taken on an empty stomach, at bedtime, or specifically avoided with food.

3. A healthcare professional is preparing to administer a blood transfusion to a client. Which of the following actions should the healthcare professional take first?

Correct answer: D

Rationale: Verifying the client's identity is the first crucial action the healthcare professional should take before administering a blood transfusion. This step ensures that the right blood is given to the right client, helping prevent errors. Obtaining vital signs, ensuring IV access, and priming IV tubing are important steps in the process but verifying the client's identity takes precedence for patient safety and accurate care delivery.

4. A client with a new diagnosis of hypertension is receiving discharge teaching. Which statement by the client indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C because limiting saturated fat intake to 7% of daily calories is a crucial component of the dietary management for hypertension. This dietary modification helps reduce the risk of cardiovascular complications. Choices A, B, and D are incorrect. Choice A is incorrect because medication adherence should not be based on symptoms like dizziness. Choice B is inadequate as blood pressure monitoring should be more frequent, preferably daily, for effective management of hypertension. Choice D is incorrect because medication for hypertension should be taken consistently as prescribed, not just when symptoms occur.

5. A nurse is caring for a client who is 24 hours postpartum and is breastfeeding her newborn. The client asks the nurse to warm up seaweed soup that the client's partner brought for her. Which of the following responses should the nurse make?

Correct answer: C

Rationale: Agreeing to heat up the seaweed soup respects the client's cultural preferences and promotes a positive postpartum experience. Seaweed soup is a traditional food in some cultures, often believed to support recovery and breastfeeding. The nurse's supportive response fosters cultural sensitivity, which is crucial in providing patient-centered care.

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