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A nurse is caring for a client with a myocardial infarction. The nurse recognizes that the most common complication in the client following a myocardial infarction is:
- A. Right ventricular hypertrophy
- B. Cardiac dysrhythmia
- C. Left ventricular hypertrophy
- D. Hyperkalemia
Correct Answer: B
Rationale: Cardiac dysrhythmias are the most common complication following a myocardial infarction due to ischemia affecting the heart's electrical conduction system, leading to arrhythmias like ventricular tachycardia or fibrillation.
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Which of the following examples represents parallel play?
- A. Jenny and Tommy share their toys.
- B. Jimmy plays with his car beside Mary, who is playing with her doll.
- C. Kevin plays a game of Scrabble with Kathy and Sue.
- D. Mary plays with a handheld game while sitting in her mother's lap.
Correct Answer: B
Rationale: Parallel play involves children playing side by side with similar toys but without direct interaction, as described in the scenario with Jimmy and Mary.
A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse's response is based on the knowledge that hemodialysis works by:
- A. Passing water through a dialyzing membrane
- B. Eliminating plasma proteins from the blood
- C. Lowering the pH by removing nonvolatile acids
- D. Filtering waste through a dialyzing membrane
Correct Answer: D
Rationale: Hemodialysis filters waste products and excess fluids through a dialyzing membrane, mimicking kidney function.
The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?
- A. Macaroni and cheese
- B. Shrimp with rice
- C. Turkey breast
- D. Spaghetti with meat sauce
Correct Answer: C
Rationale: Turkey breast is lean and has the lowest saturated fat content compared to the other options, which contain higher-fat ingredients.
The nurse is assessing the abdomen. The nurse knows the best sequence to perform the assessment is:
- A. Inspection, auscultation, palpation
- B. Auscultation, palpation, inspection
- C. Palpation, inspection, auscultation
- D. Inspection, palpation, auscultation
Correct Answer: A
Rationale: The correct sequence is inspection, auscultation, palpation to avoid altering bowel sounds or causing discomfort during the exam.
The physician has ordered a low-purine diet for a client with gout. Which protein source is high in purine?
- A. Dried beans
- B. Nuts
- C. Cheese
- D. Eggs
Correct Answer: A
Rationale: Dried beans are high in purines, which can increase uric acid levels and exacerbate gout symptoms.