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A client with a history of myocardial infarction is prescribed aspirin. What is the primary purpose of this medication?
- A. Reduce fever.
- B. Prevent platelet aggregation.
- C. Relieve chest pain.
- D. Lower cholesterol.
Correct Answer: B
Rationale: Aspirin prevents platelet aggregation, reducing the risk of thrombus formation in clients with a history of myocardial infarction.
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A 7-year-old child with type 1 diabetes is admitted with diabetic ketoacidosis. Which intervention should the nurse prioritize?
- A. Administer insulin infusion
- B. Provide oral glucose
- C. Increase dietary carbohydrates
- D. Administer sodium bicarbonate
Correct Answer: A
Rationale: Insulin infusion is the priority in diabetic ketoacidosis to halt ketogenesis and correct hyperglycemia, addressing the underlying metabolic crisis.
The nurse working in the mental health unit is collecting data on a newly admitted client. Which data is a primary type of subjective data collection?
- A. Client complains of a headache.
- B. Client's blood pressure is 145/88.
- C. Family member states that the client got into a fight.
- D. Police officer reports that a disturbance was created by the client.
Correct Answer: A
Rationale: Assessments are conducted by many professionals, including nurses, psychiatrists, social workers, dietitians, and other therapists. Subjective data include information that can be described or verified only by the client or family. The primary source of data is the client. Objective data can be observed or measured. Secondary sources of data may need to be collected if the client is experiencing psychosis, muteness, or catatonia. These sources of data include family, friends, neighbors, police officers, health care workers, and medical records.
Which of the following is a priority nursing diagnosis for the client presenting with pelvic inflammatory disease?
- A. Imbalanced nutrition: Less than body requirements.
- B. Bathing/hygiene self-care deficit.
- C. Acute pain.
- D. Impaired skin integrity.
Correct Answer: C
Rationale: Acute pain is the priority diagnosis for pelvic inflammatory disease, as it is a hallmark symptom requiring immediate management.
A client with a diagnosis of gastroesophageal reflux disease (GERD) has just received a breakfast tray. The nurse notices that which is the only food that will increase the lower esophageal sphincter (LES) pressure and thus lessen the client's symptoms?
- A. Coffee
- B. Nonfat milk
- C. Fresh scrambled eggs
- D. Whole wheat toast with butter
Correct Answer: B
Rationale: Foods that increase the LES pressure will decrease reflux and lessen the symptoms of GERD. The food substance that will increase the LES pressure is nonfat milk. The other substances listed decrease the LES pressure, thus increasing reflux symptoms. Aggravating substances include chocolate, coffee, fatty foods, and alcohol and should be avoided in the diet of a client with GERD.
A client with a history of chronic kidney disease is prescribed calcium carbonate (Tums). The nurse should instruct the client to:
- A. Take the medication between meals.
- B. Take the medication with meals.
- C. Avoid taking the medication with dairy products.
- D. Stop the medication if constipation occurs.
Correct Answer: B
Rationale: Calcium carbonate should be taken with meals to bind phosphate in the gut, managing hyperphosphatemia in kidney disease.