Nokea
A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm as shown below. What action by the nurse is most important?
- A. Assess the client's blood pressure and level of consciousness.
- B. Call the health care provider or the Rapid Response Team.
- C. Obtain a permit for an emergency temporary pacemaker insertion.
- D. Prepare to administer antidysrhythmic medication.
Correct Answer: A
Rationale: The correct action is to assess the client's blood pressure and level of consciousness. This is crucial in a client with an inferior wall MI to monitor for potential complications like cardiogenic shock. Assessing these vital signs can provide immediate information on the client's hemodynamic stability. Calling the health care provider or Rapid Response Team may be necessary based on assessment findings. Obtaining a permit for a temporary pacemaker insertion and preparing to administer antidysrhythmic medication are not the most immediate priorities and may not address the client's current needs.
You may also like to solve these questions
A nurse is caring for a client with a new diagnosis of type 1 diabetes. What is the most important aspect of teaching the nurse should focus on?
- A. The importance of regular exercise
- B. Proper administration of insulin
- C. Maintaining a low-carbohydrate diet
- D. Recognizing signs of hyperglycemia
Correct Answer: B
Rationale: The correct answer is B, proper administration of insulin, because it is crucial for managing type 1 diabetes. Insulin is essential for regulating blood sugar levels in type 1 diabetes patients. Without proper insulin administration, the client's condition can deteriorate rapidly. Regular exercise (A) and a low-carbohydrate diet (C) are important aspects of diabetes management, but they are not as critical as ensuring proper insulin administration. Recognizing signs of hyperglycemia (D) is important, but knowing how to administer insulin correctly takes precedence in effectively managing type 1 diabetes.
A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (SATA)
- A. Age
- B. Hypertension
- C. Obesity
- D. Smoking
Correct Answer: B
Rationale: Step-by-step rationale:
1. Hypertension is a modifiable risk factor as it can be controlled through lifestyle changes and medication.
2. Age is a non-modifiable risk factor, as it naturally increases the risk of coronary artery disease.
3. Obesity is a modifiable risk factor, as weight management through diet and exercise can reduce the risk.
4. Smoking is a modifiable risk factor, as quitting smoking can significantly reduce the risk.
Summary:
B is correct as it is a modifiable risk factor that can be actively managed. A, C, and D are incorrect as age is non-modifiable and obesity and smoking are modifiable but were not selected as correct options.
What priority nursing action should you take?
- A. Notify the physician immediately
- B. Administer supplemental oxygen
- C. Have the student breathe into a paper bag
- D. Obtain an order for an anxiolytic medication
Correct Answer: C
Rationale: Breathing into a paper bag can help rebalance carbon dioxide levels in a patient experiencing hyperventilation.
When caring for a client with pneumonia, what intervention is most effective in preventing the spread of infection?
- A. Administer prescribed antibiotics on time.
- B. Encourage the client to use a tissue when coughing.
- C. Place the client in a private room.
- D. Perform hand hygiene before and after client contact.
Correct Answer: D
Rationale: The correct answer is D because performing hand hygiene before and after client contact is crucial in preventing the spread of infection in pneumonia. This intervention helps in reducing the transmission of infectious agents from one client to another and from surfaces to clients. It is a fundamental infection control measure that minimizes the risk of spreading pathogens. Option A is important for treating the infection but does not directly prevent its spread. Option B is a good practice to contain respiratory secretions but may not be as effective as hand hygiene. Option C isolates the client but does not address the primary mode of transmission through contaminated hands.
You are reviewing the drug list of an elderly client who is on several medications prescribed by different specialists for various health problems. The client reports 'lately there has been a roaring sound in my ears.' You notify the prescriber of which medication?
- A. gentamicin sulfate (Garamycin)
- B. metoprolol (Lopressor)
- C. amoxicillin (Amoxil)
- D. warfarin (Coumadin)
Correct Answer: A
Rationale: Gentamicin is an ototoxic medication that can cause tinnitus or hearing loss, warranting notification of the prescriber.