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A patient is admitted to the hospital with an acute myocardial infarction. The nurse should prioritize which of the following actions?
- A. Administering pain medication
- B. Performing a head-to-toe assessment
- C. Establishing an intravenous line
- D. Administering oxygen
Correct Answer: D
Rationale: Correct Answer: D - Administering oxygen
Rationale:
1. Oxygen is crucial in acute myocardial infarction to improve oxygenation and reduce myocardial workload.
2. Administering oxygen helps alleviate ischemia and prevents further damage.
3. Prioritizing oxygenation before pain medication or assessment ensures immediate intervention for the patient's well-being.
Summary of other choices:
A: Administering pain medication - Important for comfort but not the priority in acute myocardial infarction.
B: Performing a head-to-toe assessment - Necessary but not as urgent as ensuring oxygenation.
C: Establishing an intravenous line - Helpful but not as critical as administering oxygen in this scenario.
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Which of the following is the most appropriate response for a nurse caring for a client who is experiencing a stroke?
- A. Perform a neurological assessment
- B. Initiate a stroke protocol
- C. Position the client on their side
- D. Start a CT scan
Correct Answer: B
Rationale: The correct answer is B: Initiate a stroke protocol. This is the most appropriate response because time is critical in treating a stroke. By initiating a stroke protocol, the nurse ensures that the client receives prompt and appropriate care, including timely evaluation, imaging studies, and potential interventions such as administering clot-busting medication. Performing a neurological assessment (A) is important but may delay crucial interventions. Positioning the client on their side (C) is essential for airway protection but should not be the initial priority. Starting a CT scan (D) is important for diagnosis but should not delay the initiation of the stroke protocol, which includes obtaining imaging studies.
A nurse is caring for a patient with a history of stroke. The nurse should prioritize which of the following interventions?
- A. Encouraging mobility to prevent pressure ulcers.
- B. Monitoring for signs of deep vein thrombosis (DVT).
- C. Administering antihypertensive medication.
- D. Providing psychological support.
Correct Answer: B
Rationale: Step 1: Stroke patients are at increased risk for DVT due to immobility.
Step 2: Monitoring for DVT signs is crucial for early detection and prevention.
Step 3: Prompt intervention can prevent life-threatening complications.
Step 4: Encouraging mobility (Choice A) is important but not the priority.
Step 5: Administering antihypertensive meds (Choice C) may be necessary but not the priority.
Step 6: Providing psychological support (Choice D) is important but not as critical as DVT monitoring.
A 32-year-old patient shares with the nurse that she has been unwell for 2 weeks. She has had a variety of symptoms and has been treating them with herbs that her mother has provideThe nurse should:
- A. tell the patient that it is the herbs that are making her feel unwell.
- B. ask the patient more about the effects of the herbs.
- C. take a sample of the herbs to send to the laboratory for analysis.
- D. ask the patient's mother to explain the use of the herbs.
Correct Answer: B
Rationale: The correct answer is B because the nurse needs more information to assess the situation effectively. By asking the patient more about the effects of the herbs, the nurse can gather crucial details about the patient's condition and the potential impact of the herbs on her health. This will help the nurse make an informed decision on the appropriate course of action.
Choice A is incorrect because jumping to conclusions without gathering more information can be detrimental to the patient's care. Choice C is incorrect as sending the herbs for analysis may not provide immediate insights into the patient's condition. Choice D is incorrect as the focus should be on directly obtaining information from the patient rather than involving a third party.
When formulating diagnostic statements, what would the nurse use?
- A. Rationale
- B. American Nurses Association recommendations
- C. Physical assessment skills
- D. Diagnostic reasoning
Correct Answer: D
Rationale: The correct answer is D: Diagnostic reasoning. When formulating diagnostic statements, nurses use diagnostic reasoning to analyze data, identify patterns, and make accurate clinical judgments. This process involves critical thinking and synthesizing information to reach a conclusion. Physical assessment skills (C) are important in data collection but not the primary focus in formulating diagnostic statements. Rationale (A) refers to providing reasons or justifications and is not directly related to the diagnostic process. American Nurses Association recommendations (B) may guide nursing practice but are not specifically used in formulating diagnostic statements.
The nurse is assessing orientation in a 79-year-old patient. Which of the following responses would lead the nurse to conclude that this patient is oriented?
- A. I know that my name is John. I couldn't tell you where I am. I think this year is 2009, though.
- B. I know that my name is John, but to tell you the truth, I get kind of confused about the date.
- C. I know that my name is John; I guess I'm at the hospital in Victoria. No, I don't know the date.
- D. I know that my name is John. I am at the hospital in Victoria. I couldn't tell you what date it is, but I know that it is February of a new year"”2009.
Correct Answer: D
Rationale: The correct answer is D because the patient demonstrates orientation to person (knows their name), place (knows they are at the hospital in Victoria), and time (knows it is February of a new year – 2009). This indicates intact orientation across all three domains.
Choice A is incorrect as the patient is unsure of their location and the year. Choice B is incorrect as the patient is confused about the date. Choice C is incorrect as the patient is uncertain about the date and only guesses their location.