what should the nurse do if a patient presents with chest pain and possible acute coronary syndrome

ATI RN

ATI Capstone Medical Surgical Assessment 2 Quizlet

1. What should the healthcare provider do if a patient presents with chest pain and possible acute coronary syndrome?

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

Correct answer: A

Rationale: Administering sublingual nitroglycerin is the priority action in the treatment of chest pain in acute coronary syndrome. Nitroglycerin helps dilate blood vessels, improving blood flow to the heart and relieving chest pain. Aspirin can also be given to reduce clot formation, but nitroglycerin takes precedence in providing immediate relief. Obtaining cardiac enzymes and assessing heart sounds are important steps in the diagnostic process but do not address the immediate need to relieve chest pain and prevent cardiac tissue damage. Therefore, administering sublingual nitroglycerin is the most appropriate initial intervention for a patient presenting with chest pain and possible acute coronary syndrome.

2. A nurse is providing discharge teaching to a client who is starting to take carbidopa/levodopa to treat Parkinson's disease. Which of the following instructions should the nurse include in the teaching?

A. This medication can cause your urine to turn a dark color.
B. Expect immediate relief after taking this medication.
C. Take the medication with a high protein food.
D. Skip a dose of the medication if you experience dizziness.

Correct answer: A

Rationale: The correct instruction to include in the teaching is that carbidopa/levodopa can cause the client's urine to turn a dark color, which is a harmless effect. It is crucial for the nurse to educate the client about this common side effect. Choice B is incorrect because immediate relief is not expected; therapeutic effects may take weeks to months. Choice C is incorrect as carbidopa/levodopa should be taken on an empty stomach to enhance absorption. Choice D is incorrect as the client should not skip doses without consulting their healthcare provider, even if they experience dizziness.

3. What are the manifestations of osteomyelitis?

A. Localized pain, swelling, erythema
B. Elevated white blood cells
C. Elevated calcium levels
D. Low potassium levels

Correct answer: A

Rationale: Osteomyelitis often manifests as localized pain, swelling, and erythema due to infection in the bone. These symptoms are characteristic of inflammation and infection in the bone tissue. Elevated white blood cells (Choice B) may be present as part of the body's immune response to the infection but are not specific manifestations of osteomyelitis. Elevated calcium levels (Choice C) and low potassium levels (Choice D) are not typically associated with osteomyelitis.

4. What lab value should be prioritized in a patient with HIV?

A. CD4 T-cell count below 180 cells/mm3
B. White blood cell count
C. Serum albumin levels
D. Hemoglobin levels

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. Monitoring the CD4 T-cell count is crucial in patients with HIV as it indicates the level of immunocompromise. A count below 180 cells/mm3 signifies severe immunocompromise and an increased risk of opportunistic infections. Choices B, C, and D are not the priority lab values in HIV management. While white blood cell count, serum albumin levels, and hemoglobin levels are important, they do not directly reflect the immune status and progression of HIV as the CD4 T-cell count does.

5. A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following findings should the nurse notify the provider?

A. The dressing was changed 7 days ago
B. The circumference of the client's upper arm has increased by 10%
C. The catheter has not been used in 8 hours
D. The catheter has been flushed with 10 mL of sterile saline after medication use

Correct answer: B

Rationale: An increase in the circumference of the client's upper arm by 10% could indicate deep vein thrombosis, which is a serious condition. Deep vein thrombosis can impede blood flow and potentially lead to life-threatening complications. Therefore, the nurse should notify the provider immediately about this finding. Choice A is not an immediate concern as PICC dressing changes are usually done every 7 days. Choice C is a normal finding as catheters may not be used for certain periods. Choice D is a correct procedure for maintaining catheter patency after medication use.