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After the nurse indicates chest pain protocol, which of the following is the priority diagnostic test?
- A. PT and INR
- B. 12 lead ECG
- C. Chest X-ray
- D. D-dimer test
Correct Answer: C
Rationale: The correct answer is C: Chest X-ray. When a patient presents with chest pain, a chest X-ray is crucial to evaluate for any acute cardiopulmonary conditions like pneumonia, pneumothorax, or aortic dissection. It helps identify any immediate life-threatening issues that require prompt intervention. PT and INR (A) are coagulation tests not typically indicated for acute chest pain. A 12-lead ECG (B) is important but usually done after the chest X-ray to assess for cardiac abnormalities. D-dimer test (D) is used to rule out pulmonary embolism, but it is not the priority test in the initial evaluation of chest pain.
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Which of the following information is the priority for the nurse to discuss?
- A. Reviewing information about support groups for individual who have had a stroke
- B. obtaining an alert system to get help in case of a fall
- C. providing information about available transportation resources
- D. choosing an agency to provide home physical therapy
Correct Answer: B
Rationale: The correct answer is B: obtaining an alert system to get help in case of a fall. This is the priority for the nurse to discuss because falls can lead to serious injuries, so having a system in place to quickly get help is crucial for the patient's safety. Reviewing support groups (A) is important but not as urgent as fall prevention. Transportation resources (C) and home physical therapy agency (D) are important but secondary to immediate safety concerns.
A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect?
- A. Zinc
- B. Calcium
- C. Folate
- D. Iron
Correct Answer: C
Rationale: The correct answer is C: Folate. Folate is essential for preventing neural tube defects in newborns. It helps in the development of the baby's brain and spinal cord. Zinc (A) is important for overall health but not specifically for preventing neural tube defects. Calcium (B) is crucial for bone health, not neural tube development. Iron (D) is vital for preventing anemia but not directly related to neural tube defects.
The nurse should set the IV infusion to deliver how many ml/hr?
- A. mL/hr
- B. 11.0 mL/hr
- C. 6.0 mL/hr
- D. 16.0 mL/hr
Correct Answer: B
Rationale: The correct answer is B: 11.0 mL/hr. This is the correct answer because the question asks how many mL/hr the nurse should set the IV infusion to deliver. The specific rate of 11.0 mL/hr is likely calculated based on the patient's individual needs, prescribed fluid volume, and the desired rate of administration. Option A is too general and does not provide a specific rate. Options C and D are incorrect as they do not match the recommended rate of 11.0 mL/hr given in the question.
Which statement should the nurse make?
- A. Your desire to be an organ donor must be documented in writing
- B. You have the right to change your decision about organ donation at any time.
- C. Discussing your wishes with your family can help ensure they are honored.
- D. Organ donation does not delay funeral arrangements or affect body appearance.
- E. Medical care provided before death will not be affected by your organ donor status.
Correct Answer: E
Rationale: The correct answer is E because it addresses a common misconception. Organ donor status does not affect medical care provided before death. Choice A is incorrect as organ donor consent can also be verbal. Choice B is incorrect because changing one's decision about organ donation may not always be feasible in emergency situations. Choice C is incorrect as discussing wishes with family does not guarantee they will be honored legally. Choice D is incorrect as organ donation may have some impact on funeral arrangements and body appearance.
Which of the following laboratory values should the nurse monitor?
- A. Liver function tests
- B. kidney function tests
- C. hemoglobin and hematocrit
- D. serum sodium and potassium
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Monitoring liver function is crucial as it assesses the health of the liver, detecting any abnormalities or diseases. Liver function tests include assessing levels of enzymes, proteins, and bilirubin. Abnormal results can indicate liver damage or dysfunction. Monitoring kidney function (B) is important but not the priority in this scenario. Hemoglobin and hematocrit (C) are essential for assessing blood health but not specific to liver function. Serum sodium and potassium (D) are more related to electrolyte balance than liver function.