Nokea
A client is seen in the emergency room with complaints of chest pain.
- A. Which assessment finding suggests to the nurse that the client’s chest pain is cardiac in origin?
- B. The client states that the pain is sharp and increased by deep breathing.
- C. The client reports a history of a fatty meal before the pain began.
- D. The client states that the pain is substernal and radiates to the left arm.
- E. The client reports that the pain began when he was lifting a heavy object.
Correct Answer: C
Rationale: Substernal chest pain radiating to the left arm is a classic symptom of cardiac ischemia, such as angina or myocardial infarction. Sharp pain with breathing suggests pleuritic causes, fatty meals indicate gastroinTest inal issues, and pain with lifting suggests musculoskeletal strain.
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A postoperative client has a nasogastric (NG) tube following bowel surgery. The orders read, 'acetaminophen 650 PRN for fever above 101°F.' The client has a temperature of 101.4°F. What is the most appropriate nursing action?
- A. Administer the acetaminophen by rectal suppository.
- B. Administer the acetaminophen by elixir through the NG tube and turn suction off for 30 minutes.
- C. Administer the acetaminophen by crushing two tablets, giving it through the NG tube, and turning suction off for 30 minutes.
- D. Call the physician and question the order.
Correct Answer: A
Rationale: A rectal suppository is appropriate with an NG tube on suction, ensuring fever treatment without risking medication loss.
A 19-year-old woman after delivery of a 7 lb 10 oz baby boy. The patient has decided to bottle-feed her infant.
The nurse should encourage the patient to
- A. use the manual breast pump to relieve breast engorgement.
- B. apply warm packs to the breast to relieve discomfort.
- C. massage the breasts to reduce engorgement and discomfort.
- D. wear a well supportive bra and take Tylenol for discomfort.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will encourage milk secretion (2) will enhance flow of milk (3) may be taut due to engorgement, massage would be painful and unnecessary, will encourage milk flow (4) correct-will help minimize discomfort during period of engorgement
The nurse is caring for a client with an electrical burn. Which structures have the greatest risk for soft tissue injury?
- A. Fat, tendons, and bones
- B. Skin and hair
- C. Nerves, muscle, and blood vessels
- D. Skin, fat, and muscle
Correct Answer: A
Rationale: Fat, tendon, and bone have the most resistance. The higher the resistance, the greater the heat generated by the current, thereby increasing the risk for soft tissue injury. Answer B has intermediate resistance, so it is incorrect. Answer C is incorrect because it has very low resistance. Answer D has low to intermediate resistance, so it is incorrect.
An adult is admitted with suspected urolithiasis. Which nursing diagnosis is of highest priority when planning nursing care for this client immediately after admission?
- A. Acute pain
- B. Diarrhea
- C. Risk of ineffective health maintenance
- D. Risk of infection
Correct Answer: A
Rationale: Kidney stones cause severe pain, making acute pain the priority diagnosis for immediate relief and comfort. Other diagnoses are secondary.
A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?
- A. Altered nutrition: less than body requirements
- B. Potential complication hemorrhage
- C. Ineffective individual coping
- D. Fluid volume excess
Correct Answer: B
Rationale: Potential complication hemorrhage. Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk for rupture if portal circulation pressures rise.