a patient with a history of hypertension is admitted for chest pain what is the most appropriate action for the nurse to take first
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B

1. A patient with a history of hypertension is admitted for chest pain. What is the most appropriate action for the nurse to take first?

Correct answer: B

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient presenting with chest pain as it helps dilate blood vessels, reduce chest pain, and improve oxygen supply to the heart. Obtaining a detailed medical history, conducting an ECG, or administering morphine sulfate are important steps in the assessment and treatment process but are secondary to the immediate need to address chest pain and potential cardiac ischemia.

2. A nurse manager is teaching a group of employees about standards for Quality and Safety Education for Nurses (QSEN). Which of the following statements by an employee should the nurse manager identify as an example of the QSEN concept of quality improvement?

Correct answer: B

Rationale: Involving partners in care planning is a quality improvement strategy that aligns with QSEN principles. This choice reflects patient-centered care and collaboration, which are essential elements of quality improvement. Choices A, C, and D do not directly relate to quality improvement concepts. Tracking discharge times, logging out of computers, and providing change-of-shift reports are important practices but not specifically focused on quality improvement.

3. A nurse is caring for a patient with heart failure who has developed pulmonary edema. What is the nurse's priority action?

Correct answer: B

Rationale: The correct answer is to place the patient in a high Fowler's position. This position helps improve lung expansion and oxygenation in cases of pulmonary edema by reducing venous return to the heart and enhancing respiratory mechanics. Administering a diuretic (Choice A) can be important but is not the priority over positioning in this situation. Administering oxygen (Choice C) is essential, but the priority action for improving oxygenation is the positioning of the patient. Monitoring lung sounds (Choice D) is crucial for ongoing assessment but is not the priority action when the patient is in distress with pulmonary edema.

4. A healthcare provider is reviewing a client's lab results. Which of the following lab values should the provider report?

Correct answer: C

Rationale: The correct answer is C: Sodium 126 mEq/L. A sodium level of 126 mEq/L is below the normal range, indicating hyponatremia, which can have serious health implications and should be reported to the healthcare provider for further evaluation and intervention. Choices A, B, and D are within or close to the normal ranges for magnesium, potassium, and chloride, respectively, and do not require immediate reporting as they are not significantly abnormal.

5. A nurse manager on an acute care unit is preparing a staff presentation about promoting cost-effective care. Which of the following strategies should the nurse plan to include in the presentation?

Correct answer: D

Rationale: Teaching staff proper use of PPE helps reduce the spread of infections and promotes cost-effective care.

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