Nokea
A client with a history of gastroesophageal reflux disease (GERD) is admitted with chest pain. The nurse should prioritize which of the following interventions?
- A. Obtain a 12-lead ECG.
- B. Administer omeprazole.
- C. Position the client supine.
- D. Administer an antacid.
Correct Answer: A
Rationale: Chest pain in GERD may mimic cardiac pain, so obtaining a 12-lead ECG rules out myocardial infarction.
You may also like to solve these questions
Identify this cardiac rhythm strip. Fill in the blank. A. Third Degree Heart Block B. Second-Degree Atrioventricular Block, Type II C. Ventricular fibrillation D. Premature Atrial Contractions
- B. Third Degree Heart Block
- C. Second-Degree Atrioventricular Block, Type II
- D. Ventricular fibrillation
- E. Premature Atrial Contractions
Correct Answer: A
Rationale: Third Degree Heart Block shows complete dissociation between P waves and QRS complexes, assuming the strip matches this description.
A client is receiving a continuous infusion of heparin. The nurse notes a partial thromboplastin time (PTT) of 120 seconds. What should the nurse do first?
- A. Stop the infusion
- B. Reduce the infusion rate
- C. Administer protamine sulfate
- D. Notify the physician
Correct Answer: A
Rationale: A PTT of 120 seconds is significantly above the therapeutic range (1.5 to 2 times normal), indicating a risk of bleeding. Stopping the infusion is the first action to prevent harm.
A client is prescribed risperidone. Which laboratory study should the nurse anticipate to be prescribed before the initiation of this medication therapy?
- A. Platelet count
- B. Blood clotting tests
- C. Liver function studies
- D. Complete blood count
Correct Answer: C
Rationale: Risperidone is an atypical antipsychotic medication that suppresses behavioral response in psychosis. Baseline assessment includes renal and liver function tests, and these studies should be done before the initiation of treatment. This medication is used with caution in clients with renal or hepatic impairment, clients with underlying cardiovascular disorders, and in older or debilitated clients. None of the other options are related to the administration of this medication.
Which member of the multidisciplinary team would you most likely collaborate with when your pediatric client has had a traumatic amputation one or more months ago?
- A. A Pedorthist
- B. A pediatric nurse practitioner
- C. A trauma certified clinical nurse specialist
- D. A prosthetist
Correct Answer: D
Rationale: A prosthetist specializes in designing and fitting prosthetic limbs, making them the most appropriate team member to collaborate with for a pediatric client with a traumatic amputation.
The nurse is performing an assessment on a 6-month-old infant suspected of having hydrocephalus. Which finding is associated with this diagnosis?
- A. A bulging anterior fontanel
- B. An elevated apical heart rate
- C. The presence of protein in the urine
- D. A drop in blood pressure from baseline
Correct Answer: A
Rationale: A bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle, which occurs in hydrocephalus. An elevated apical heart rate, proteinuria, and a drop in blood pressure are not specifically related to increasing cerebrospinal fluid in the brain tissue.