what is the first action a nurse should take for a patient with possible acute coronary syndrome

ATI RN

ATI Capstone Adult Medical Surgical Assessment 2

1. What is the first action a healthcare provider should take for a patient with possible acute coronary syndrome?

A. Administer sublingual nitroglycerin
B. Get IV access
C. Auscultate heart sounds
D. Obtain cardiac enzymes

Correct answer: A

Rationale: Administering sublingual nitroglycerin is the initial priority action for a patient with possible acute coronary syndrome. Nitroglycerin helps dilate blood vessels, reduce chest pain, and improve blood flow to the heart muscle. This helps in relieving symptoms and preventing further damage to the heart. Establishing IV access, auscultating heart sounds, and obtaining cardiac enzymes are important steps in the assessment and management of acute coronary syndrome but are not the first actions to be taken. IV access may be needed for administering medications or fluids, auscultating heart sounds helps in assessing the heart's function, and obtaining cardiac enzymes aids in diagnosing a heart attack.

2. What is a typical symptom of a hemorrhagic stroke in a patient?

A. Sudden, severe headache
B. Gradual onset of numbness
C. Loss of consciousness
D. Loss of speech ability

Correct answer: A

Rationale: A sudden, severe headache is a common symptom of a hemorrhagic stroke due to brain bleeding. This headache is often described as the worst headache of one's life. Gradual onset of numbness (choice B) is more characteristic of an ischemic stroke, where a blood clot blocks an artery in the brain. Loss of consciousness (choice C) can occur in severe cases of stroke but is not specific to hemorrhagic strokes. Loss of speech ability (choice D) is more associated with ischemic strokes affecting language centers of the brain.

3. What is a characteristic sign of hypokalemia on an ECG?

A. Flattened T waves
B. ST elevation
C. Prominent U waves
D. Widened QRS complex

Correct answer: A

Rationale: Flattened T waves are a characteristic sign of hypokalemia on an ECG. When potassium levels are low, it can lead to changes in the ECG, such as T wave flattening. This alteration is important to recognize as it indicates potential electrolyte imbalances. ST elevation (Choice B) is not typically associated with hypokalemia but can be seen in conditions like myocardial infarction. Prominent U waves (Choice C) are associated with hypokalemia, but flattened T waves are more specific. Widened QRS complex (Choice D) is not a typical ECG finding in hypokalemia but can be seen in conditions like hyperkalemia.

4. Which ECG change is associated with hyperkalemia?

A. Flattened T waves
B. Prominent U waves
C. Elevated ST segments
D. Widened QRS complex

Correct answer: A

Rationale: Flattened T waves are a characteristic ECG change seen in hyperkalemia. Hyperkalemia affects the repolarization phase of the cardiac cycle, leading to T wave abnormalities. Prominent U waves are typically seen in hypokalemia. Elevated ST segments are more indicative of myocardial infarction or pericarditis. Widened QRS complexes are commonly associated with conditions like bundle branch blocks or certain toxicities.

5. The nurse misread a patient's glucose as 210 mg/dL instead of 120 mg/dL and administered the insulin dose for a reading over 200 mg/dL. What is the priority action?

A. Administer glucose IV
B. Monitor for hyperglycemia
C. Monitor for hypoglycemia
D. Document the incident

Correct answer: C

Rationale: The priority action is to monitor the patient for signs of hypoglycemia as the nurse administered excess insulin due to misreading the glucose level. Administering glucose IV (Choice A) is not the immediate priority when dealing with hypoglycemia. Monitoring for hyperglycemia (Choice B) is not the correct action as the insulin was administered for a higher glucose reading. Documenting the incident (Choice D) is important but not the priority when the patient's safety is at risk due to possible hypoglycemia.