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A nurse is assessing a client with a history of myocardial infarction who is in the surgical unit following a gastric resection. The client complains of chest pains. The nurse obtains the electrocardiogram (ECG) shown (see figure). What should the nurse do first?
- A. Administer oxygen.
- B. Inspect the client's incision.
- C. Call the rapid response team.
- D. Reposition the ECG electrodes.
Correct Answer: A
Rationale: Chest pain post-myocardial infarction suggests possible cardiac ischemia, so administering oxygen is the priority to improve oxygenation. The other actions follow after initial stabilization.
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A 13-year-old male was kidnapped and held for ransom by two criminals. His parents asked to have him admitted to the adolescent psychiatric unit. He is sleep-deprived, filthy, alternating between sobbing and making threats to kill his captors, and then asks to go to sleep. What is the best initial plan for this client?
- A. Encourage him to talk with the Federal Bureau of Investigation (FBI) about the crime details.
- B. Develop trust and allow him to talk about his memories and feelings.
- C. Help him and his parents prepare for the future trial.
- D. Discourage him from making threats toward his captors.
Correct Answer: B
Rationale: Building trust and allowing the client to express feelings addresses immediate emotional needs and trauma, prioritizing mental health support.
The nurse is evaluating a diabetic client's understanding of the signs of hyperglycemia. Which statement by the client reflects an understanding?
- A. I may become diaphoretic and faint.
- B. I may notice signs of fatigue, dry skin, and increased urination.
- C. I need to take an extra diabetic pill if my blood glucose is greater than 300.
- D. I should restrict my fluid intake if my blood glucose is greater than 250.
Correct Answer: B
Rationale: Fatigue, dry skin, polyuria, and polydipsia are classic symptoms of hyperglycemia. Fatigue occurs because of lack of energy from the inability of the body to use glucose. Dry skin occurs secondary to dehydration related to polyuria. Polydipsia occurs secondary to fluid loss. Diaphoresis is associated with hypoglycemia. A client should not take extra hypoglycemic agents to reduce an elevated blood glucose level. A client with hyperglycemia becomes dehydrated secondary to the osmotic effect of the elevated glucose; therefore, the client must increase fluid intake.
A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is prescribed tiotropium (Spiriva). The nurse should instruct the client to:
- A. Use the inhaler as needed for shortness of breath.
- B. Rinse the mouth after using the inhaler.
- C. Shake the inhaler before use.
- D. Take two puffs twice daily.
Correct Answer: B
Rationale: Rinsing the mouth after using tiotropium prevents oral candidiasis, a common side effect of inhaled anticholinergics.
A client has been taking benzonatate as prescribed. The nurse should tell the client this medication performs which action?
- A. Increases comfort level
- B. Decreases anxiety level
- C. Calms the persistent cough
- D. Takes away nausea and vomiting
Correct Answer: C
Rationale: Benzonatate is a locally acting antitussive. Its effectiveness is measured by the degree to which it decreases the intensity and frequency of cough, without eliminating the cough reflex. The remaining options are not intended effects of this medication.
A client has undergone a mastectomy. The nurse determines that the client is having the most difficulty adjusting to the loss of the breast when which behavior is observed?
- A. Refuses to look at the dressing
- B. Requires help with sponge bathing
- C. Asks that the nurse limit visitors to only family
- D. Dresses in a loose nightgown the client brought from home
Correct Answer: A
Rationale: The client demonstrates the most difficult adjustment to the loss if she refuses to look at the dressing. This indicates that the client is not ready or willing to begin to acknowledge and cope with the surgery. Requiring help with sponge bathing is expected after major surgery, limiting visitors is also an expected behavior soon after surgery, and dressing in her own nightgown indicates that the client is retaining her self-esteem.