Nokea
A nurse taking a patient's history realizes the patient is complaining of SOB and weakness in the lower extremities. The patient has a history of hyperlipidemia, and hypertension. Which of the following may be occurring?
- A. The patient is developing CHF
- B. The patient may be having a MI
- C. The patient may be developing COPD
- D. The patient may be having an onset of PVD
Correct Answer: B
Rationale: Myocardial infarction may be associated with SOB and muscle weakness.
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Which of these actions should the nurse perform first when a client is admitted with a diagnosis of C-difficile?
- A. Initiate contact precautions
- B. Administer prescribed antibiotics
- C. Obtain a stool culture
- D. Educate the client about hand hygiene
Correct Answer: A
Rationale: Initiating contact precautions is the first step to prevent the spread of C-difficile, which is highly contagious through contact with contaminated surfaces or feces.
Serum Vancomycin levels are taken to measure which of the following?
- A. renal function
- B. therapeutic range
- C. trough levels
- D. antibiotic resistance
Correct Answer: B
Rationale: Vancomycin levels are monitored to ensure therapeutic effects by peak level.
The charge nurse is planning assignments on a medical unit. Which client should be assigned to the practical nurse (PN)?
- A. Test a stool specimen for occult blood
- B. Assist with the ambulation of a client with a chest tube system
- C. Irrigate and redress a leg wound
- D. Admit a client from the emergency room
Correct Answer: C
Rationale: The PN is a licensed provider and can perform this complex task. Irrigating and redressing a leg wound requires clinical skills appropriate for a PN, whereas the other tasks are either simpler or require an RN.
Hearing screening of prematurely born infants is an effective means of identifying disease and is an example of:
- A. primary prevention.
- B. secondary prevention.
- C. tertiary prevention.
- D. disability prevention.
Correct Answer: B
Rationale: The three levels of prevention address disease and disability across all phases, from absence of disease and at risk for disease, to preventing further impairment. Hearing impairment associated with prematurity cannot be prevented by screening, but identifying the infants with hearing loss might prevent sequelae and further impairment by allowing early intervention.
The nurse is assessing a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)?
- A. 8-Apr
- B. 15-Jan
- C. 11-Feb
- D. 23-Dec
Correct Answer: D
Rationale: December 23. Naegele's rule states: Add 7 days and subtract 3 months from the first day of the last regular menstrual period to calculate the estimated date of delivery.