the client is on nitroglycerin and reports chest pain what is the nurses priority action
Logo

Nursing Elites

ATI RN

Cardiovascular System Exam Questions

1. The client is on nitroglycerin and reports chest pain. What is the nurse’s priority action?

Correct answer: D

Rationale: The correct answer is D: Notify the healthcare provider immediately. If a client on nitroglycerin reports chest pain, the priority action is to notify the healthcare provider immediately. This is crucial to ensure prompt reassessment of the client's condition and treatment plan. Administering nitroglycerin, morphine, or aspirin without consulting the healthcare provider first can be risky as the chest pain may indicate a need for a change in treatment or further evaluation. Administering medications without proper assessment and guidance can lead to complications and is not recommended in this scenario.

2. The client has a prescription for sublingual nitroglycerin. What is the nurse's instruction for how to take this medication during an episode of chest pain?

Correct answer: A

Rationale: The correct answer is A. The standard instruction for sublingual nitroglycerin during an episode of chest pain is to take one tablet every 5 minutes, up to three tablets. If the pain persists after taking three tablets, the client should seek emergency help. Choice B is incorrect because taking one tablet every hour is not the appropriate dosing for acute chest pain. Choice C is incorrect as taking two tablets immediately is not in line with the recommended dosing instructions. Choice D is incorrect because sublingual nitroglycerin should be placed under the tongue, not swallowed with water.

3. Which type of heart disease involves the stiffening of the heart muscle, reducing its ability to relax and fill with blood?

Correct answer: A

Rationale: The correct answer is A, restrictive cardiomyopathy. This condition specifically involves the stiffening of the heart muscle, leading to a reduced ability to relax and fill with blood between beats. Choice B, hypertrophic cardiomyopathy, is characterized by abnormal thickening of the heart muscle, not stiffening. Choice C, dilated cardiomyopathy, involves the enlargement and weakening of the heart chambers, not stiffening. Choice D, ventricular hypertrophy, refers to the thickening of the walls of the heart's pumping chambers but does not specifically involve the stiffening that is characteristic of restrictive cardiomyopathy.

4. The client on digoxin has a potassium level of 2.7 mEq/L. What is the nurse’s priority action?

Correct answer: A

Rationale: The correct answer is to hold the digoxin and notify the healthcare provider. A potassium level of 2.7 mEq/L is considered low and can increase the risk of digoxin toxicity. Holding the medication and informing the healthcare provider is crucial to prevent adverse effects. Administering the digoxin as ordered (Choice B) would put the client at a higher risk for toxicity. Increasing the dose of digoxin (Choice C) is not appropriate when the client's potassium level is low. Administering potassium supplements (Choice D) may be necessary but is not the priority action in this situation.

5. Which condition involves the body's immune system attacking the lungs and kidneys, causing severe respiratory and renal damage?

Correct answer: A

Rationale: Goodpasture syndrome is the correct answer. It is an autoimmune disease characterized by the immune system attacking the lungs and kidneys, leading to bleeding in the lungs and kidney failure. Sarcoidosis primarily affects the lungs and lymph nodes, not the kidneys. Wegener's granulomatosis affects the lungs, sinuses, and kidneys, but it is characterized by inflammation of blood vessels. Interstitial lung disease involves scarring of the lung tissue, not direct immune system attacks on the lungs and kidneys.

Similar Questions

Which artery supplies the anterior wall of the left ventricle, the anterior interventricular septum, the anterior papillary muscles, and apex of the heart?
The client on warfarin has an INR of 3.8. What is the most appropriate action by the nurse?
What is a surgical procedure to replace a damaged or diseased heart valve with a prosthetic valve?
The client is on dobutamine. Adverse effects of Dobutrex (dobutamine) include the following: Select all that apply.
What is a type of heart disease that involves the thickening or stiffening of the heart muscle, reducing its ability to pump blood?

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