Nokea
A client has an elevated AST 24 hours following chest pain and shortness of breath. This is suggestive of which of the following?
- A. Gallbladder disease
- B. Liver disease
- C. Myocardial infarction
- D. Skeletal muscle injury
Correct Answer: C
Rationale: An elevated AST level following chest pain and shortness of breath is suggestive of myocardial infarction. AST is released from damaged heart muscle cells during a heart attack, indicating cardiac involvement. This enzyme is not specific to liver disease, gallbladder disease, or skeletal muscle injury in this clinical context.
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What action should be taken when adding sterile liquids to a sterile field?
- A. Use an expired sterile liquid if the bottle is sealed and unopened.
- B. Consider the sterile field contaminated if it becomes wet during the procedure.
- C. Remove the container cap and place it with the inside facing up on the sterile field.
- D. Hold the container low and pour the solution into a receptacle at the front of the sterile field.
Correct Answer: B
Rationale: If a sterile field becomes wet or damp during a procedure, it is considered contaminated as moisture can allow organisms to wick from the surface and compromise the sterility of the field. It is essential to maintain the integrity of the sterile field to prevent infections and ensure patient safety.
The healthcare professional retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM 6 hours PRN for severe pain. How many mL should the healthcare professional administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth)
- A. 0.8 mL
- B. 0.75 mL
- C. 0.7 mL
- D. 0.9 mL
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse explains to an older adult male the procedure for collecting a 24-hour urine specimen for creatinine clearance. Which action is most important for the nurse to include in their care plan for the shift?
- A. Assess the client for confusion and reteach the procedure
- B. Check the urine for color and texture
- C. Empty the urinal contents into the 24-hour collection container
- D. Discard the contents of the urinal
Correct Answer: C
Rationale: To ensure accurate creatinine clearance results, it is crucial to collect all urine within the 24-hour period. The process should begin with discarding the first specimen and then collecting all subsequent urine in the designated 24-hour collection container. This ensures that the sample is complete and accurate for the creatinine clearance calculation.
A client is receiving external radiation therapy for lung cancer. Which intervention is most important for the nurse to include in the client's plan of care?
- A. Encourage the client to use sunscreen when outdoors.
- B. Apply a heating pad to the radiation site.
- C. Instruct the client to avoid using deodorant on the skin near the radiation site.
- D. Advise the client to increase intake of green leafy vegetables.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
At 0100 on a male client's second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?
- A. Leave the room and close the door to the client's room
- B. Assess the appearance of the client's surgical dressing
- C. Bring the client a prescribed PRN sedative-hypnotic
- D. Discuss symptoms of sleep deprivation with the client
Correct Answer: A
Rationale: The client has expressed a plan to read until feeling sleepy, indicating that he is managing his inability to sleep. In this situation, it is best for the nurse to respect the client's autonomy and leave the room, providing privacy and an opportunity for the client to relax and hopefully fall asleep. Closing the door can also help create a quiet environment conducive to rest.