Nokea
Before discharge from the hospital after a myocardial infarction, a client is taught to exercise by gradually increasing the distance walked. Which vital sign should the nurse teach the client to monitor to determine whether to increase or decrease the exercise level?
- A. Pulse rate.
- B. Blood pressure.
- C. Body temperature.
- D. Respiratory rate.
Correct Answer: A
Rationale: Monitoring pulse rate helps determine if the exercise level is appropriate, as an excessively high rate indicates overexertion.
You may also like to solve these questions
The nurse is observing an unlicensed assistive personnel (UAP) care for an older client who had surgery (insertion of a prosthesis) following a hip fracture 4 days ago. To prevent client injury, the nurse should intervene in the care when which action is performed by the UAP?
- A. Elevates the head of bed 30 degrees
- B. Assists the client in inserting dentures
- C. Obtains a bedside commode to keep in the room
- D. Places pillows between the legs when turning the client
Correct Answer: C
Rationale: After hip surgery when a prosthesis has been inserted, a client should not flex the body more than 90 degrees relative to the chair; sitting on a commode would mean a low seat. The toilet seat should be raised, so a special adapted commode should be placed in the room. The head of the bed can be raised slightly for comfort. Assisting the client in inserting dentures is within the duties of a UAP. The legs should be kept abducted, so using pillows between the legs when turning is required.
The nurse tells a rape victim that even if she was protected against pregnancy by a contraceptive and the attention of taking any legal action against her assailant, she should still be checked by a physician for early detection of which of the following?
- A. Sexually transmitted disease.
- B. Anxiety reaction.
- C. Periurethral tears.
- D. Menstrual difficulties.
Correct Answer: A
Rationale: A physician should check for sexually transmitted diseases, as rape increases the risk of infection, which requires early detection and treatment.
The nurses in the neonatal intensive care unit are not identifying important clinical changes in the clients that need to be documented. The unit director should initiate which of the following actions? Select all that apply.
- A. Identify the problem at a staff meeting without placing blame on any individual or group.
- B. Ask the unit staff to develop a plan that they think will solve this problem.
- C. Ask an experienced nurse to spend time reorienting newer staff members.
- D. Collaborate with the staff development educator to develop a plan.
- E. Ask the neonatologist to give a presentation about assessing newborns.
Correct Answer: A,C,D,E
Rationale: Addressing the issue without blame, involving staff in solutions, reorienting newer staff, collaborating with educators, and arranging expert presentations are all effective strategies to improve documentation.
The nurse is providing care to the client who has received medication therapy with tissue plasminogen activator. Which item should the nurse have available for use as part of standard nursing care for this client?
- A. Flashlight
- B. Pulse oximeter
- C. Suction equipment
- D. Occult blood test strips
Correct Answer: D
Rationale: Tissue plasminogen activator is a thrombolytic medication that is used to dissolve thrombi or emboli caused by thrombus. A frequent and potentially adverse effect of therapy is bleeding. The nurse monitors for signs of bleeding in clients receiving this therapy. Equipment needed by the nurse would include occult blood test strips to monitor for occult blood in the urine, stool, or nasogastric drainage. A flashlight may be used for pupil assessment as part of the neurological exam in the client who is neurologically impaired. Pulse oximeter and suction equipment would be needed if the client had evidence of respiratory problems.
Which of the following is a nursing diagnosis that reflects some unexpected response to a therapy?
- A. Episiotomy extension related to a forceps delivery
- B. Respiratory depression related to NSAIDs
- C. Hemothorax related to a latex allergy
- D. All of the above
Correct Answer: D
Rationale: All listed diagnoses reflect unexpected responses to therapies (forceps delivery, NSAIDs, latex exposure), qualifying as adverse reactions.