Nokea
A client is admitted with a suspected myocardial infarction. The nurse should prioritize which of the following interventions?
- A. Administer aspirin as ordered.
- B. Obtain a 12-lead ECG.
- C. Insert an I.V. line.
- D. Administer morphine for pain.
Correct Answer: B
Rationale: Obtaining a 12-lead ECG is the priority to confirm myocardial infarction and guide treatment.
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A client with a history of asthma reports increased wheezing. Which medication should the nurse prepare to administer?
- A. Prednisone.
- B. Albuterol.
- C. Montelukast.
- D. Cromolyn sodium.
Correct Answer: B
Rationale: Albuterol, a short-acting beta-agonist, is the first-line treatment for acute asthma exacerbations to relieve bronchospasm.
The lack of necessary supplies and equipment to adequately and safely care for patients is an example of a (n):
- A. Sentinel event.
- B. System variance.
- C. Adverse effect.
- D. Provider variance.
Correct Answer: B
Rationale: The lack of necessary supplies and equipment is a system variance , as it reflects a failure in the healthcare system's resources, impacting safe care delivery.
The nurse is administering epoetin alfa to a client diagnosed with chronic kidney disease (CKD). For which adverse effect of this therapy should the nurse monitor the client?
- A. Anemia
- B. Hypertension
- C. Iron intoxication
- D. Bleeding tendencies
Correct Answer: B
Rationale: The client taking epoetin alfa is at risk of hypertension and seizure activity as the most serious adverse effects of therapy. This medication is used to treat anemia. The medication does not cause iron intoxication. Bleeding tendencies is not an adverse effect of this medication.
A newborn diagnosed with respiratory distress syndrome (RDS) is prescribed surfactant replacement therapy. The nurse evaluates the infant 1 hour after the therapy and determines that the infant's condition has improved somewhat. Which finding indicates improvement?
- A. An audible respiratory grunt
- B. Slight increase in the respiratory rate
- C. Arterial blood pH increases to ≥ 7.35
- D. Fine inspiratory crackles heard over both lungs
Correct Answer: C
Rationale: RDS causes hypoperfusion with hypoxemia that results in tissue hypoxia and metabolic acidosis. If the arterial blood pH increases to ≥ 7.35, the metabolic acidosis is resolving and the newborn's condition is improving. Within a few hours, respiratory distress becomes more obvious in RDS. The respiratory rate continues to increase (to 80 to 120 breaths/min), so a gradual increase in rate does not mean that the condition is improving. Also, an audible respiratory grunt and fine inspiratory crackles heard over both lungs are not signs the condition is improving.
The nurse identifies the type of presentation shown in the fi gure as which of the following?
- A. Frank breech.
- B. Compound breech.
- C. Complete breech.
- D. Incomplete breech.
Correct Answer: C
Rationale: For a complete breech, the buttocks present, the feet and legs are fl exed on the thighs, and the thighs are fl exed on the abdomen. For a frank breech, the buttocks present with the hips fl exed and the legs extended against the abdomen and chest. This is the most common type of breech presentation. For a compound breech, the buttocks present together with another part, such as a hand. This is a rare occurrence. For an incomplete breech, one or both feet or the knees extend below the buttocks. This can also be termed a single footling or double footling breech.