A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication does the nurse anticipate being prescribed by the healthcare provider?
- A. Morphine.
- B. Oxycodone.
- C. Hydromorphone.
- D. Fentanyl.
Correct Answer: A
Rationale: Morphine is typically prescribed for myocardial infarction symptoms to relieve pain and reduce cardiac workload.
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A nurse is caring for a patient who has been admitted to the hospital with a suspected diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the patient for?
- A. Lumbar puncture.
- B. Skull radiography.
- C. Magnetic resonance imaging (MRI).
- D. Computerized tomography (CT) scan.
Correct Answer: A
Rationale: A lumbar puncture is essential for confirming bacterial meningitis by analyzing cerebrospinal fluid, making it the priority diagnostic procedure.
What information should the nurse include in the teaching plan for a patient diagnosed with gastroesophageal reflux disease (GERD)?
- A. The patient should adjust their food intake to three full meals per day with no snacks.
- B. The patient should avoid participating in any aerobic exercise programs.
- C. The patient should sleep without pillows at night to maintain neck alignment.
- D. The patient should wear loose, comfortable clothing to minimize symptoms.
Correct Answer: D
Rationale: Wearing loose clothing reduces pressure on the abdomen, helping to minimize GERD symptoms by preventing reflux.
The nurse is caring for a client who reports a sudden, severe facial numbness. The nurse observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse perform immediately?
- A. Maintain elevated positioning of the dependent joints on the affected side.
- B. Verify prescribed laboratory tests include prothrombin time and platelet count.
- C. Start two large-bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
- D. Administer aspirin to prevent further clot formation and platelet clumping.
Correct Answer: C
Rationale: Symptoms suggestive of a stroke require immediate initiation of IV access and evaluation for fibrinolytic therapy to restore cerebral blood flow.
An hour after administering 60 mg of furosemide intravenously (IV), which assessments should the nurse perform to determine the patient's response to treatment?
- A. Urinary output.
- B. Skin elasticity.
- C. Pain scale.
- D. Lung sounds.
- E. Oxygen saturation.
Correct Answer: A,D,E
Rationale: Assessing urinary output, lung sounds, and oxygen saturation evaluates furosemide's effectiveness in reducing fluid overload and improving respiratory status.
A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide?
- A. Painful areas should be rubbed gently until the pain subsides.
- B. Wearing gloves when handling cold items guards against painful spasms.
- C. Return appointments will be needed for IV pain medication.
- D. Enrolling in a pain clinic can provide pain relief alternatives.
Correct Answer: B
Rationale: Wearing gloves prevents cold-induced spasms, reducing pain in Raynaud's disease.
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