how should a nurse respond to a patient experiencing acute chest pain

ATI LPN

ATI NCLEX PN Predictor Test

1. How should a healthcare provider respond to a patient experiencing acute chest pain?

A. Administer prescribed nitroglycerin
B. Provide oxygen
C. Call for emergency assistance
D. Reassure the patient

Correct answer: A

Rationale: In the case of a patient experiencing acute chest pain, the initial response should include administering prescribed nitroglycerin. Nitroglycerin helps dilate blood vessels and improve blood flow to the heart, which can be beneficial in managing chest pain related to cardiac issues. Providing oxygen can also be helpful to support oxygenation. However, the priority in this scenario is to address the potential cardiac cause by administering nitroglycerin. Calling for emergency assistance is crucial if the patient's condition does not improve or deteriorates. Reassuring the patient is essential for emotional support but should not be the primary intervention in the case of acute chest pain.

2. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

A. A client who was just given a glass of orange juice for a low blood glucose level.
B. A client who is scheduled for a procedure in 1 hr.
C. A client who has 100 mL fluid remaining in his IV bag.
D. A client who received a pain medication 30 min ago for postoperative pain.

Correct answer: A

Rationale: The client with low blood glucose needs immediate assessment to ensure that the orange juice has corrected the hypoglycemia. Monitoring the effectiveness of the intervention for low blood glucose is the priority. The other options, such as a client scheduled for a procedure in 1 hour, a client with fluid remaining in the IV bag, and a client who received pain medication 30 minutes ago, do not require immediate assessment like the client with low blood glucose.

3. A client with heart failure is on a fluid restriction. What should the nurse include in the discharge teaching?

A. Encourage the client to drink more water to stay hydrated
B. Monitor the client's weight daily
C. Avoid drinking water after 6 PM
D. Monitor fluid intake only during meals

Correct answer: B

Rationale: The correct answer is B: 'Monitor the client's weight daily.' In clients with heart failure on fluid restriction, monitoring daily weight is crucial to track fluid balance. This allows healthcare providers to assess if the client is retaining excess fluid, a common issue in heart failure. Choices A, C, and D are incorrect. Encouraging the client to drink more water contradicts the fluid restriction; avoiding drinking water after 6 PM is not specific to managing fluid restriction; and monitoring fluid intake only during meals does not provide a comprehensive assessment of fluid balance throughout the day.

4. What is the priority intervention when managing a client with delirium?

A. Administer antipsychotic medication to calm the client
B. Identify any reversible causes of delirium
C. Provide a low-stimulation environment
D. Administer sedative medication to control agitation

Correct answer: B

Rationale: The correct answer is to identify any reversible causes of delirium. Delirium is often caused by underlying issues such as infections, medication side effects, or metabolic imbalances. Addressing these root causes can help resolve delirium more effectively. Administering antipsychotic or sedative medications should not be the initial approach as they can worsen delirium in some cases. Providing a low-stimulation environment is beneficial but not the priority when reversible causes need to be addressed first.

5. What are the signs of opioid withdrawal, and how should it be managed?

A. Sweating, nausea; administer methadone
B. Muscle cramps, vomiting; administer naloxone
C. Tremors, sweating; administer buprenorphine
D. Fever, agitation; provide sedatives

Correct answer: A

Rationale: The signs of opioid withdrawal typically include sweating and nausea. The correct management approach involves administering methadone to alleviate the symptoms. Choice B is incorrect because naloxone is used to reverse opioid overdose, not for managing withdrawal symptoms. Choice C is incorrect as buprenorphine is typically used to treat opioid addiction, not just withdrawal symptoms. Choice D is incorrect as sedatives are not the primary treatment for opioid withdrawal.