Nokea
A client is admitted to the coronary care unit with an acute myocardial infarction. The pain associated with acute myocardial infarction results from:
- A. Spasm of the coronary artery
- B. Ischemia of the myocardium
- C. Vasodilation of the coronary veins
- D. Ischemia of the carotid artery
Correct Answer: B
Rationale: Myocardial infarction pain is caused by ischemia of the myocardium due to reduced blood flow, leading to tissue hypoxia.
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The nurse is talking with a client who is entering the second trimester of pregnancy. Which of the following information should the nurse include? Select all that apply.
- A. Anticipate experiencing light fetal movements around 16 to 20 weeks gestation
- B. Increase your consumption of iron-rich foods like meat and dried fruit
- C. Try to gain about 3 lb (1.4 kg) each week if your prepregnancy BMI was normal
- D. Expect to have an abdominal ultrasound scheduled to check fetal anatomy
- E. Plan to be screened for gestational diabetes mellitus around 24 to 28 weeks gestation
Correct Answer: A,B,D,E
Rationale: Fetal movement, iron intake, anatomy ultrasound, and diabetes screening are standard second-trimester recommendations. Weight gain should be about 1 lb/week for normal BMI, not 3 lb.
The RN charge nurse hands the LPN/LVN a syringe filled with medication that the RN has just drawn and asks the LPN/LVN to administer this to a client. How should the LPN/LVN respond?
- A. Do as requested by the charge nurse
- B. Ask the charge nurse what the medication is and then administer it
- C. Ask the charge nurse what the medication is, check the order, and then administer it
- D. Refuse to administer the medication
Correct Answer: C
Rationale: Verifying the medication and checking the order ensures safe administration, adhering to medication safety protocols. Blind administration or refusal is unsafe or uncooperative.
After receiving shift report, the nurse is assessing a client started on trimethoprim-sulfamethoxazole 2 days ago for treatment of a urinary tract infection. The client reports itching, and the nurse notices a diffuse maculopapular rash on the client's face. What should the nurse do first?
- A. Administer diphenhydramine
- B. Administer injectable epinephrine
- C. Examine the client's trunk and limbs
- D. Reassess the client's allergy history
Correct Answer: C
Rationale: Examining the trunk and limbs determines the rash’s extent, guiding whether it’s a mild reaction or a severe one (e.g., Stevens-Johnson syndrome). Diphenhydramine, epinephrine, or allergy reassessment are secondary until the rash is fully assessed.
A client who has Mycoplasma pneumonia needs to go to the radiology department for a chest x-ray. What should the client wear?
- A. A face shield
- B. A surgical mask
- C. An N95 respirator
- D. Gloves and a gown
Correct Answer: B
Rationale: A surgical mask prevents droplet transmission of Mycoplasma pneumonia during transport, protecting others.
The nurse cares for a confused client who continues to pull at the intravenous (IV) catheter on the left forearm despite frequent instructions not to do so. What is the nurse's next action?
- A. Apply a gauze wrap and elastic stockinette around the IV site
- B. Apply a mitt on the right hand
- C. Apply a soft wrist restraint on the right wrist
- D. Apply an arm board to the left arm
Correct Answer: D
Rationale: An arm board on the left arm stabilizes the IV site, reducing pulling without restraining the client, aligning with least-restrictive interventions. Mitts or restraints on the right side do not protect the left-sided IV.