Nokea
A nurse is caring for a client with a suspected myocardial infarction. Which of the following laboratory results should the nurse prioritize?
- A. Elevated troponin levels
- B. Decreased hemoglobin
- C. Increased potassium
- D. Elevated white blood cell count
Correct Answer: A
Rationale: Troponin is a specific marker for myocardial damage and is critical in diagnosing myocardial infarction. Other results are less specific to this condition.
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A client with a history of peptic ulcer disease reports epigastric pain. Which action should the nurse take first?
- A. Administer an antacid.
- B. Notify the physician.
- C. Offer a light snack.
- D. Assess the pain characteristics.
Correct Answer: D
Rationale: Assessing pain characteristics provides data to determine the cause and severity, guiding further interventions.
Methylergonovine maleate is prescribed for a woman who has just delivered a healthy newborn. Which is the priority assessment to complete before administering the medication?
- A. Lochia
- B. Uterine tone
- C. Blood pressure
- D. Deep tendon reflexes
Correct Answer: C
Rationale: Methylergonovine maleate, an oxytocic, is an agent used to prevent or control postpartum hemorrhage by contracting the uterus. The immediate dose is administered intramuscularly, and then, if still needed, it is administered orally. It causes uterine contractions and may elevate the blood pressure. A priority assessment before administration of methylergonovine maleate is blood pressure. Methylergonovine maleate is to be administered cautiously in the presence of hypertension, and the primary health care provider should be notified if hypertension is present. Options 1 and 2 are general components of care in the postpartum period. Option 4 is most specifically related to the administration of magnesium sulfate.
During a home visit to a primiparous client 1 week postpartum who is bottle-feeding her neonate, the clientiant tells the nurse that her mother has suggested that she feed the neonate cereal so he will sleep through the night. Which of the following would be the nurse's best response?
- A. It is permissible to give the baby cereal if it is thinned with formula.'
- B. The time for starting cereal varies, so check with your pediatrician.'
- C. Formula is the food best digested by the baby until about 4 to 6 months of age.'
- D. If cereal is given too early in life, the undigested food can lead to a need for surgery.'
Correct Answer: C
Rationale: Formula is best for infants until 4-6 months, as early introduction of solids like cereal can cause digestive issues.
Select the legal term that is accurately paired with its description.
- A. Assault: Touching a person without their consent
- B. Battery: Threatening to touch a person without their consent
- C. Slander: False oral defamatory statements.
- D. Slander: False written defamatory statements.
Correct Answer: C
Rationale: Slander is correctly defined as false oral defamatory statements. Assault is threatening harm , battery is unauthorized touching , and libel is false written defamation .
A client is receiving a tube feeding and has developed diarrhea, cramps, and abdominal distention. Which of the following interventions would be most appropriate? Select all that apply.
- A. Change the feeding apparatus every 24 hours.
- B. Use a higher volume of formula because the normal loss of the blood pressure.
- C. Slow the administration rate.
- D. Use a diluted formula, gradually increasing the volume and concentration.
- E. Anticipate changing to a lactose-free formula.
Correct Answer: A, C, D, E
Rationale: Changing the apparatus, slowing the rate, using diluted formula, and switching to lactose-free formula help manage diarrhea and distention.