A patient is being cared for by a nurse who has a history of angina and is experiencing chest pain. Which of the following actions should the nurse take first?

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Question 1 of 5

A patient is being cared for by a nurse who has a history of angina and is experiencing chest pain. Which of the following actions should the nurse take first?

Correct Answer: C

Rationale: In a patient with a history of angina experiencing chest pain, the priority action for the nurse is to obtain a 12-lead ECG. This helps in assessing for myocardial infarction, a serious condition that requires immediate attention. Administering oxygen, nitroglycerin, or notifying the healthcare provider can be important interventions but obtaining the ECG comes first to determine the presence of myocardial infarction and guide further management.

Question 2 of 5

A healthcare professional is assessing a client who is 24 hours postoperative following an open cholecystectomy. Which of the following findings should the healthcare professional report to the provider?

Correct Answer: D

Rationale: A WBC count of 15,000/mm³ is elevated and may indicate infection, which should be reported. High WBC count is a sign of inflammation or infection, and in a postoperative client, it can be indicative of surgical site infection or another complication. Urinary output, serosanguineous wound drainage, and a heart rate of 94/min are all within normal ranges for a client post cholecystectomy and do not raise immediate concerns for infection or complications.

Question 3 of 5

A client who has a new diagnosis of tuberculosis should be placed in which type of room to prevent the spread of airborne pathogens?

Correct Answer: D

Rationale: Clients diagnosed with tuberculosis should be placed in a negative pressure room to prevent the spread of airborne pathogens. Option A is incorrect because administering isoniazid is a treatment for tuberculosis, not a preventive measure related to infection control. Option B is incorrect as droplet isolation is used for diseases transmitted through respiratory droplets, not airborne pathogens like tuberculosis. Option C is incorrect as wearing a surgical mask is not sufficient to prevent the spread of tuberculosis in healthcare settings; placing the client in a negative pressure room is the most effective measure.

Question 4 of 5

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

Correct Answer: C

Rationale: A respiratory rate of 26/min is a sign of respiratory distress and should be reported promptly in a client with pneumonia. Rapid breathing can indicate inadequate oxygenation and ventilation, which may lead to respiratory failure. Crackles in the lung bases are common in pneumonia but may not be as urgent as a high respiratory rate. A blood pressure of 100/64 mm Hg is slightly low but may not be immediately life-threatening. A heart rate of 86/min is within the normal range for an adult and is not the most critical finding to report.

Question 5 of 5

A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following instructions should the nurse include?

Correct Answer: A

Rationale: The correct instruction the nurse should include is to advise the client to avoid consuming foods high in vitamin K. Foods rich in vitamin K, such as leafy greens, can interfere with the effectiveness of warfarin, an anticoagulant medication. Therefore, it is important for clients on warfarin therapy to maintain consistent vitamin K intake to keep their INR levels stable. The other options are also important but not the priority in the context of warfarin therapy. Ingesting foods high in vitamin K can affect the medication's efficacy, making it crucial to highlight this dietary consideration during client education.

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