what is the appropriate action for a patient experiencing chest pain

ATI RN

ATI RN Exit Exam

1. What is the appropriate action for a patient experiencing chest pain?

A. Administer aspirin
B. Reposition the patient
C. Check oxygen saturation
D. Prepare for surgery

Correct answer: A

Rationale: The correct action for a patient experiencing chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation in patients with chest pain, as it has antiplatelet effects. Repositioning the patient may not address the underlying cause of the chest pain. Checking oxygen saturation is important but not the initial priority in this scenario. Surgery is not typically the first-line treatment for chest pain without further assessment and diagnostic procedures.

2. Which lab value is essential for a patient receiving warfarin therapy?

A. Monitor INR
B. Monitor sodium levels
C. Monitor potassium levels
D. Monitor platelet count

Correct answer: A

Rationale: The correct answer is to monitor the INR (International Normalized Ratio) for a patient receiving warfarin therapy. INR monitoring is crucial to assess the effectiveness of warfarin in preventing blood clots while minimizing the risk of bleeding. Monitoring sodium levels (choice B), potassium levels (choice C), or platelet count (choice D) is not specifically essential for patients on warfarin therapy and does not provide direct information on the drug's anticoagulant effects.

3. A nurse is reviewing the medical record of a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?

A. Glucose 180 mg/dL
B. Sodium 136 mEq/L
C. Potassium 3.8 mEq/L
D. Albumin 3.5 g/dL

Correct answer: A

Rationale: The correct answer is A: "Glucose 180 mg/dL." Elevated glucose levels in a client receiving TPN may indicate hyperglycemia, which can lead to complications such as osmotic diuresis, dehydration, and electrolyte imbalances. It is essential to report this finding to the provider for further evaluation and management. Choices B, C, and D are within normal ranges and do not indicate immediate concerns related to TPN administration.

4. A nurse is caring for a client who has a pneumothorax and is being treated with a chest tube. Which of the following findings indicates that the lung has re-expanded?

A. There is no fluctuation in the water seal chamber.
B. There is continuous bubbling in the suction control chamber.
C. There is tidaling in the water seal chamber.
D. The drainage system is positioned at the level of the client's chest.

Correct answer: A

Rationale: The correct answer is A: 'There is no fluctuation in the water seal chamber.' In a client with a pneumothorax being treated with a chest tube, the absence of fluctuation in the water seal chamber indicates that the lung has re-expanded. This finding suggests that there is no air leak from the lung into the pleural space. Choices B and C are incorrect because continuous bubbling in the suction control chamber or tidaling in the water seal chamber would suggest ongoing air leakage, indicating that the lung has not fully re-expanded. Choice D is also incorrect as the position of the drainage system does not directly indicate lung re-expansion.

5. A nurse is caring for a client who has a history of angina. The client reports chest pain. Which of the following actions should the nurse take?

A. Administer sublingual nitroglycerin every 5 minutes
B. Administer aspirin 325 mg
C. Encourage the client to use deep breathing exercises
D. Apply oxygen at 2 L/min via nasal cannula

Correct answer: A

Rationale: The correct action for the nurse to take when a client with a history of angina reports chest pain is to administer sublingual nitroglycerin every 5 minutes. Nitroglycerin helps dilate blood vessels, improving blood flow to the heart and relieving chest pain associated with angina. Aspirin is often given during a suspected heart attack, not for immediate relief of angina. Deep breathing exercises may be beneficial for anxiety or respiratory conditions but are not the first-line intervention for angina. Oxygen therapy is not the initial treatment for angina unless the client is hypoxic.