Nokea
An adult male calls his nurse neighbor and says he is having severe chest pain and feels as though something terrible is happening to him. He rates his pain as 10 on the 10-point scale. In addition to calling 911, what should the nurse recommend the man do now?
- A. Take an aspirin
- B. Lie flat
- C. Take some deep breaths
- D. Go to bed
Correct Answer: A
Rationale: Aspirin reduces clot formation in suspected myocardial infarction, improving outcomes, and should be taken immediately.
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A 25-year-old primigravida with type I diabetes mellitus.
The nurse explains to the client that her insulin needs will
- A. increase during pregnancy and decrease after delivery.
- B. decrease during pregnancy and increase after delivery.
- C. increase during pregnancy and remain increased after delivery.
- D. decrease during pregnancy and fluctuate after delivery.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-needs increase during pregnancy due to hormonal interference in glucose metabolism (2) needs increase during pregnancy due to hormonal interference in glucose metabolism (3) insulin needs will decrease after delivery (4) needs increase during pregnancy
A preschool client's mother reports that the child has frequent bouts of gastroenteritis.
It would be MOST important for the nurse to ask which of the following questions?
- A. Are there other children in the family?'
- B. Does the child attend a day care center?'
- C. Does the child play with neighborhood children?'
- D. Is the child current on his immunizations?'
Correct Answer: B
Rationale: Strategy: Determine why the nurse would make the assessment and how it relates to gastroenteritis. (1) does not pose a problem or solution regarding gastroenteritis (2) correct-environments with increased numbers of children (day care) more likely to promote infections due to close living conditions and increased likelihood of disease transmission (3) possible source of infection, but not as likely as a day care center (4) does not pose a problem or solution regarding gastroenteritis
The nurse is caring for a client who had a cholecystectomy. Which of the following observations is MOST important for the nurse to report to the next shift?
- A. Resting after receiving IM pain medication.
- B. No bowel sounds present.
- C. IV infusing at 100 cc/h.
- D. Breath sounds decreased in both lower lobes.
Correct Answer: D
Rationale: Decreased breath sounds suggest atelectasis or pneumonia, serious post-cholecystectomy complications due to reduced ventilation from pain. Options A, B, and C are routine: resting is expected, absent bowel sounds are normal post-surgery, and IV rate is standard.
The nurse is caring for a client receiving chemotherapy.
- A. Which symptom should the nurse report immediately for a client receiving chemotherapy?
- B. Nausea and vomiting.
- C. A temperature of 100.8°F (38.2°C).
- D. Fatigue and weakness.
- E. Alopecia.
Correct Answer: B
Rationale: A temperature of 100.8°F indicates possible infection, a life-threatening complication in chemotherapy patients due to immunosuppression. Nausea, fatigue, and alopecia are expected side effects but less urgent.
A teenaged client states that she drinks 'lots' of fluids and still feels thirsty.
It is MOST important for the nurse to ask which of the following questions?
- A. Has your weight recently changed?'
- B. What medications do you take?'
- C. Do you have any allergies to food or medication?'
- D. How often do you menstruate?'
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to the symptoms. (1) correct-excessive thirst and weight loss are two notable symptoms of diabetes mellitus (IDDM) (2) does not provide useful information related to the assessment information (3) does not provide useful information related to the assessment information (4) does not provide useful information related to the assessment information