ATI RN
ATI Nur 221 Med Surg Exam Cardiac Questions
Extract:
Question 1 of 5
A nurse in a provider's clinic is assessing a client who takes sublingual nitroglycerin for stable angina. The client reports getting a headache each time he takes the medication. Which of the following statements should the nurse make?
Correct Answer: A
Rationale: Try taking a mild analgesic to relieve the headache.' is correct. Nitroglycerin-induced headaches are a common side effect due to vasodilation. Mild analgesics such as acetaminophen can help alleviate the discomfort. Taking only one dose to reduce the risk of a headache is inappropriate. The client should follow the prescribed dosing regimen to manage angina effectively. Skipping doses may increase the risk of angina attacks. Requesting a different medication is not necessary. Nitroglycerin is an effective treatment for stable angina, and headaches typically diminish over time as the body adjusts to the medication. Stating that nothing can be done to relieve the headaches is incorrect. Headaches from nitroglycerin can be managed with mild analgesics or by adjusting the timing of medication administration.
Question 2 of 5
A client has chronic obstructive pulmonary disease (COPD) and right-sided heart failure. Which statement by the nurse is correct?
Correct Answer: A
Rationale: Eating six small meals a day limits oxygen demand during digestion and prevents bloating, aiding breathing. Excessive fluids, lying down, and protein intake adjustments are not appropriate.
Question 3 of 5
The nurse and unlicensed assistive personnel (UAP) are caring for an elderly client diagnosed with emphysema. Which nursing tasks could be delegated to the UAP to improve gas exchange? (Select All that Apply)
Correct Answer: C,D,E
Rationale: Encouraging deep breathing exercises (
C), recording pulse oximeter readings (
D), and keeping the head of bed elevated (E) can be delegated to a UAP to improve gas exchange. Assessing consciousness and auscultating breath sounds require nursing judgment.
Question 4 of 5
A client with a history of heart failure on daily weights has a 2-pound weight gain and pitting edema in bilateral lower extremities. Which action should the nurse take next?
Correct Answer: C
Rationale: Performing a head-to-toe assessment, including vital signs, is correct. A 2-pound weight gain and edema suggest fluid retention, requiring assessment for worsening heart failure symptoms like crackles or respiratory distress. Encouraging fluid intake, monitoring without action, or checking code status are not immediate priorities.
Extract:
Nurses Notes
Client presents to the ED with substernal chest pain that comes and goes. The client states that the pain has been occurring for the last 8 hr. The pain, at times radiates down the left arm. Client also reports intermittent nausea
Client appears pale and slightly diaphoretic. Client rates current pain as 7 on a scale of 0 to 10
Question 5 of 5
Client presents to the ED with substernal chest pain that comes and goes. The client states that the pain has been occurring for the last 8 hr. The pain, at times radiates down the left arm. Client also reports intermittent nausea Client appears pale and slightly diaphoretic. Client rates current pain as 7 on a scale of 0 to 10. A nurse is caring for a client in the emergency department (ED). The nurse is planning care for the client. For each potential prescription. indicate whether it is indicated, nonessential, or contraindicated.
| Options | Non- Anticipated | Essential | Contraindicated |
|---|---|---|---|
| Obtain intravenous (IV) access | |||
| Obtain the client's family history | |||
| Apply continuous ECG monitoring | |||
| Administer Oâ‚‚ to maintain oxygen saturation greater than 90% |
Correct Answer: A,C,D
Rationale: Obtain intravenous (IV) access (
A), apply continuous ECG monitoring (
C), and administer Oâ‚‚ if saturation is below 90% (
D) are indicated for suspected MI. Obtaining family history (
B) is nonessential in the acute phase.