Nokea
A 60-year-old male client comes into the emergency department with a complaint of crushing substernal chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Immediate admission orders include oxygen by nasal cannula at 4 L/minute, blood work, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given I.V. The nurse should first:
- A. Administer the morphine.
- B. Obtain a 12-lead ECG.
- C. Obtain the blood work.
- D. Order the chest radiograph.
Correct Answer: A
Rationale: Administering morphine first relieves pain, reducing myocardial oxygen demand and stabilizing the client. ECG and blood work follow to confirm diagnosis, but pain management is the priority.
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The nurse will anticipate which of the following problems that can result for the older adult undergoing abdominal surgery?
- A. Uncrossed scarring.
- B. Decreased melanin and melanocytes.
- C. Decreased healing.
- D. Increased immunocompetence.
Correct Answer: C
Rationale: Older adults have slower wound healing due to reduced collagen synthesis and cellular turnover, increasing the risk of delayed recovery post-surgery.
A client has been taking aluminum hydroxide (Amphojel) 30 mL six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client's constipation?
- A. The client has not been including enough fiber in his diet.
- B. The client needs to increase his daily exercise.
- C. The client is experiencing an adverse effect of the aluminum hydroxide.
- D. The client has developed a gastrointestinal obstruction.
Correct Answer: C
Rationale: Aluminum hydroxide is known to cause constipation as a common adverse effect, especially with frequent dosing. The other options are less likely given the direct association with the medication.
The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifi es this rhythm as which of the following?
- A. Atrial fi brillation
- B. Ventricular tachycardia.
- C. Premature ventricular contractions (PVCs).
- D. Third-degree heart block.
Correct Answer: C
Rationale: PVCs are early depolarizations originating in the ventricles, and they present exactly as seen in your strip.
The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations should the nurse include in the client's teaching plan? Select all that apply.
- A. Hearing loss.
- B. Visual disturbance.
- C. Headache.
- D. Orthopnea.
- E. Gout.
- F. Weight loss.
Correct Answer: B,C,D,E
Rationale: Polycythemia vera increases blood viscosity and red cell mass, leading to complications like visual disturbances (due to retinal hemorrhage), headaches (from hypertension or thrombosis), orthopnea (from heart failure), and gout (from increased uric acid due to cell turnover). Hearing loss and weight loss are not typical complications.
A 250-lb male client recovering from general anesthesia has the following assessment findings: pulse, 150 bpm; blood pressure, 90/50 mm Hg; respiratory rate, 28 breaths/minute; tympanic temperature, 99.8°F (37.7°C); and rigid muscles. The nurse determines that the client is:
- A. Recovering as expected from the anesthesia and continues monitoring him.
- B. Exhibiting the effects of excessive blood loss experienced in the operating room and increases the rate of his I.V. infusion.
- C. In the early stages of malignant hyperthermia and obtains emergency medications and notification.
- D. In pain and offers him pain medication.
Correct Answer: C
Rationale: Tachycardia, hypotension, tachypnea, and muscle rigidity suggest malignant hyperthermia, a life-threatening reaction to anesthesia. Immediate action, including emergency medications like dantrolene, is required.