A nurse is assessing a client who has a history of angina and reports chest pain. Which of the following actions should the nurse take first?

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Question 1 of 5

A nurse is assessing a client who has a history of angina and reports chest pain. Which of the following actions should the nurse take first?

Correct Answer: B

Rationale: The correct answer is to obtain a 12-lead ECG. In a client with a history of angina and reporting chest pain, the priority action is to assess for myocardial infarction, which is best done through an ECG. Administering oxygen, nitroglycerin, or notifying the provider can be important actions but obtaining an ECG takes precedence in evaluating the client's condition.

Question 2 of 5

A healthcare professional is assessing a client who has a new prescription for digoxin. Which of the following findings is the priority for the healthcare professional to report to the provider?

Correct Answer: A

Rationale: The correct answer is A. A heart rate of 58/min is indicative of bradycardia, a potential sign of digoxin toxicity, which should be reported immediately. While weight gain, respiratory rate, and temperature are important parameters to monitor, they are not as critical as identifying bradycardia in a client taking digoxin.

Question 3 of 5

A nurse is assessing a client who is receiving a continuous heparin infusion. Which of the following findings should the nurse report to the provider?

Correct Answer: D

Rationale: The correct answer is D because an INR of 1.0 is below the therapeutic range for clients receiving heparin, indicating a potential need for dosage adjustment. Platelet count (choice A) within normal range, aPTT (choice B) within therapeutic range, and hemoglobin level (choice C) are not directly related to the monitoring of heparin therapy and would not require immediate reporting to the provider.

Question 4 of 5

A client has a new diagnosis of hypertension and is being taught about lifestyle changes by a nurse. Which of the following instructions should the nurse include?

Correct Answer: B

Rationale: The correct answer is B: "Exercise for 30 minutes at least 5 days a week." Regular exercise helps promote cardiovascular health and manage hypertension. Choice A is incorrect because increasing sodium intake is not recommended for hypertension. Choice C is incorrect because while sleep is important, excessive sleep duration is not typically part of hypertension management. Choice D is incorrect because fluid intake should be adequate unless advised otherwise by a healthcare provider.

Question 5 of 5

A healthcare professional is assessing a client who is receiving opioid analgesics. Which of the following findings should the professional report to the provider?

Correct Answer: C

Rationale: A respiratory rate of 12/min may indicate respiratory depression, a potential side effect of opioid analgesics. Respiratory depression can be a serious complication that requires immediate intervention. Monitoring the respiratory rate is crucial in clients receiving opioids to prevent adverse events. Oxygen saturation, blood pressure, and heart rate are important parameters to assess, but a low respiratory rate is a more critical finding that warrants immediate reporting to the healthcare provider.

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