Nokea
A nurse is caring for a client post-myocardial infarction (MI). What is the priority assessment for this client?
- A. Monitoring urine output
- B. Checking blood glucose levels
- C. Assessing for chest pain
- D. Monitoring electrolyte levels
Correct Answer: C
Rationale: The correct answer is C: Assessing for chest pain. The priority assessment for a client post-MI is to monitor for any signs of recurrent chest pain or angina, as it could indicate ongoing cardiac ischemia or a new infarction. Prompt intervention is crucial in these situations to prevent further damage to the heart muscle. Monitoring urine output (A) and electrolyte levels (D) are important assessments but do not take precedence over assessing for chest pain. Checking blood glucose levels (B) is relevant for diabetic clients but is not the priority in this case.
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A client with tuberculosis (TB) is taking isoniazid (INH). Which instruction is most important for the nurse to include?
- A. Take the medication with food to avoid stomach upset.
- B. Avoid exposure to sunlight while taking this medication.
- C. Report any numbness or tingling in extremities.
- D. Have liver function tests done regularly.
Correct Answer: D
Rationale: Step 1: Isoniazid (INH) can cause liver toxicity.
Step 2: Regular liver function tests help monitor for liver damage.
Step 3: Monitoring liver function is crucial to prevent serious complications.
Step 4: Other choices are not directly related to INH's side effects.
Summary: Choice D is correct as it directly addresses a potential serious side effect of INH. Choices A, B, and C are not directly relevant to the medication's side effects.
A 54-year-old client has cholelithiasis and is admitted for an elective cholecystectomy. The client is 5 feet 3 inches tall, weighs 205 pounds, and has smoked one pack of cigarettes per day for 35 years. The client will be NPO at midnight. When the client's spouse asks why the client cannot have breakfast the morning before surgery, the nurse should explain:
- A. Your spouse is a good-sized person and it won't hurt to miss breakfast.
- B. Eating breakfast and having food in the stomach could cause vomiting and aspiration during surgery.
- C. Your spouse will be too busy in the morning preparing for surgery to have time to eat breakfast.
- D. Not eating breakfast will prevent fecal contamination of the abdominal operative site.
Correct Answer: B
Rationale: The client's size has nothing to do with an NPO status. Clients are at greatest risk for aspiration and vomiting during surgery when food and/or liquids are in the stomach. Preparation on the morning of surgery is time consuming, but it does not affect a client's NPO status. The gallbladder lies under the surface of the liver and is a part of the biliary tract, not the intestinal tract. Cholecystectomy does not involve the intestinal tract or its contents.
A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm as shown below. What action by the nurse is most important?
- A. Assess the client's blood pressure and level of consciousness.
- B. Call the health care provider or the Rapid Response Team.
- C. Obtain a permit for an emergency temporary pacemaker insertion.
- D. Prepare to administer antidysrhythmic medication.
Correct Answer: A
Rationale: The correct action is to assess the client's blood pressure and level of consciousness. This is crucial in a client with an inferior wall MI to monitor for potential complications like cardiogenic shock. Assessing these vital signs can provide immediate information on the client's hemodynamic stability. Calling the health care provider or Rapid Response Team may be necessary based on assessment findings. Obtaining a permit for a temporary pacemaker insertion and preparing to administer antidysrhythmic medication are not the most immediate priorities and may not address the client's current needs.
Which setting allows the dying client to have advanced care in an institution due to the necessity to control pain unable to be managed at home?
- A. Hospice care
- B. Acute care
- C. Palliative care
- D. Home care
Correct Answer: C
Rationale: Palliative care specializes in managing complex symptoms and pain, providing advanced institutional support.
Persons at risk are the target population for cancer screening programs. Which asymptomatic patient(s) needs extra encouragement to participate in cancer screening? (Choose all that apply.)
- A. A 19-year-old white-American female who is sexually inactive for a Pap smear.
- B. A 35-year-old white-American female for an annual mammogram.
- C. A 45-year-old African-American male for an annual prostate-specific antigen.
- D. A 49-year-old African-American male for an annual fecal occult blood test.
Correct Answer: D
Rationale: African-American males are at higher risk for prostate and colorectal cancers, making regular screening crucial for early detection.