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A client is hospitalized with an acute myocardial infarction. Which nursing diagnosis reflects an understanding of the cause of acute myocardial infarction?
- A. Decreased cardiac output related to damage to the myocardium
- B. Impaired tissue perfusion related to an occlusion in the coronary vessels
- C. Acute pain related to cardiac ischemia
- D. Ineffective breathing patterns related to decreased oxygen to the tissues
Correct Answer: B
Rationale: Impaired tissue perfusion due to coronary occlusion is the primary cause of acute myocardial infarction.
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The floor nurse sees a new order in a client's chart for levothyroxine (Synthroid) 125 mcg PO every day. The pharmacy sends up Synthroid 0.1 mg tablets. How many tablets should the nurse administer? Calculate and fill in the blank.
Correct Answer: 1.25
Rationale: 125 mcg = 0.125 mg. 0.125 mg ÷ 0.1 mg/tablet = 1.25 tablets.
The nurse must administer 120 mg of amoxicillin oral suspension to a child. However, the only dosage available in the pharmacy is 200 mg per 5 mL. How many milliliters of suspension should the nurse administer? Record your answer using a whole number only.
Correct Answer: 3
Rationale: Dose = 120 mg, concentration = 200 mg/5 mL = 40 mg/mL. Volume = 120 m/40 mg/mL = 3 mL.
A pediatric nurse would be concerned by which of the following sets of vital signs?
- A. newborn: BP 70/50, RR 47, HR 135
- B. 12-month-old: BP 65/55, RR 50, HR 130
- C. 10-year-old: BP 110/70, RR 16, HR 89
- D. 13-year-old: BP 120/82, RR 15, HR 80
Correct Answer: B
Rationale: 12-month-old vitals (BP 65/55, RR 50, HR 130) show low BP (normal ~90/50) and high RR (normal 20-30), suggesting distress. Other options are age-appropriate.
A client prescribed furosemide (Lasix) should choose which meal for lunch?
- A. chicken breast, white rice, apple
- B. turkey sandwich on wheat bread, celery sticks, grapefruit
- C. egg salad, cooked carrots, strawberries
- D. baked salmon, spinach salad, banana
Correct Answer: D
Rationale: Furosemide causes potassium loss. A meal with potassium-rich foods (e.g., spinach, banana) helps maintain electrolyte balance.
The nursing assistant is taking vitals for a client on mechanical ventilation. Which of the following findings should the nursing assistant report to the nurse immediately?
- A. respiratory rate 26 breaths/minute
- B. heart rate 82 beats/minute
- C. blood pressure 152/86 mmHg
- D. temperature 102.1°F
Correct Answer: D
Rationale: Fever (102.1°F) in a ventilated client suggests infection (e.g., ventilator-associated pneumonia), requiring immediate reporting.