Nokea
A 67-year-old client is admitted with substernal chest pain with radiation to the jaw. His admitting diagnosis is Acute Myocardial Infarction (MI). The priority nursing diagnosis for this client during the immediate 24 hours is
- A. Constipation related to immobility
- B. High risk for infection
- C. Impaired gas exchange
- D. Fluid volume deficit
Correct Answer: C
Rationale: The correct answer is C: Impaired gas exchange. In a client with an acute myocardial infarction, impaired gas exchange is a priority nursing diagnosis due to compromised heart function, which affects oxygenated blood circulation. Close monitoring and interventions are crucial to ensure adequate oxygenation. Choices A, B, and D are incorrect: A) Constipation related to immobility is not the priority in this acute situation; B) High risk for infection is not the immediate concern related to the client's primary diagnosis; D) Fluid volume deficit, while important, is not the priority compared to addressing impaired gas exchange in acute MI.
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When teaching a responsible family member how to perform a certain procedure for the patient, what is the best approach?
- A. Perform all these steps
- B. Arrange for the practice of the procedure
- C. Describe the procedure
- D. Demonstrate the procedure
Correct Answer: D
Rationale: The best approach when teaching a responsible family member a procedure for the patient is to demonstrate the procedure. By demonstrating, the family member can visually see how it is done, making it easier for them to understand and replicate. This hands-on approach is more effective than just describing the procedure (choice C) or arranging for practice (choice B) without a visual demonstration. Performing all the steps (choice A) may not be practical or necessary when the goal is to teach someone else how to do it.
A 14-month-old had cleft palate surgical repair several days ago. The parents ask the nurse about feedings after discharge. Which lunch is the best example of an appropriate meal?
- A. Hot dog, carrot sticks, gelatin, milk
- B. Soup, blenderized soft foods, ice cream, milk
- C. Peanut butter and jelly sandwich, chips, pudding, milk
- D. Baked chicken, applesauce, cookie, milk
Correct Answer: B
Rationale: Choice B, 'Soup, blenderized soft foods, ice cream, milk,' is the correct answer. After cleft palate repair, it is essential to provide soft and blenderized foods to prevent trauma to the surgical site and promote proper healing. Choices A, C, and D contain foods that may be difficult for the child to consume comfortably and safely after a cleft palate surgical repair. A hot dog, carrot sticks, chips, and hard cookies could potentially cause injury or discomfort to the surgical area. Peanut butter and jelly sandwich might be too difficult to swallow or may stick to the surgical site. Baked chicken could be too challenging to chew. Therefore, the best choice for an appropriate meal post cleft palate repair is soft, blenderized foods like soup, along with other soft options like ice cream and milk.
Which one of the following statements, if made by the client, indicates teaching about Inderal (propranolol) has been effective?
- A. ''I may experience seizures if I stop the medication abruptly.''
- B. ''I may experience an increase in my heart rate for a few weeks.''
- C. ''I can expect to feel nervousness the first few weeks.''
- D. ''I can have a heart attack if I stop this medication suddenly.''
Correct Answer: D
Rationale: The correct answer is D. Stopping Inderal (propranolol) abruptly can cause rebound hypertension, angina, and even a myocardial infarction (heart attack), so it is crucial to taper off the medication under medical supervision. Choices A, B, and C are incorrect because they do not reflect the serious consequences associated with abrupt discontinuation of propranolol.
An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for tracheoesophageal fistula. The mother asks, 'When can the tube be used for feeding?' The nurse's best response would be which of these comments?
- A. "Feedings can begin in 5 to 7 days."
- B. "The use of the feeding tube can begin immediately."
- C. "The stomach contents and air must be drained first."
- D. "The incision healing must be complete before feeding."
Correct Answer: C
Rationale: The correct answer is C: 'The stomach contents and air must be drained first.' Before starting feedings through a gastrostomy tube, it is essential to drain the stomach contents and air. This process helps prevent complications and ensures the proper functioning of the tube after placement. Choice A is incorrect because initiating feedings within 5 to 7 days may lead to complications if the stomach is not adequately prepared. Choice B is incorrect as feeding should not begin immediately to allow for proper preparation of the tube and the stomach. Choice D is incorrect because although incision healing is important, draining the stomach contents and air is a more immediate concern to prevent complications.
From January 1 to 15, 1996, there were 8 cases of Tetanus neonatorum in San Lazaro Hospital. There were two deaths. What is the case fatality ratio of this disease?
- A. 20%
- B. 30%
- C. 28%
- D. 25%
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.