Identify the three layers of the heart:
- A. Endocardium, Myocardium, Epicardium
- B. Epicardium, Pericardium, Endocardium
- C. Myocardium, Endocardium, Pericardium
- D. Pericardium, Myocardium, Endocardium
Correct Answer: A
Rationale: Rationale:
1. Endocardium: Innermost layer lining the heart chambers.
2. Myocardium: Middle layer composed of cardiac muscle tissue.
3. Epicardium: Outermost layer forming the visceral pericardium.
Therefore, the correct answer is A.
Summary:
B is incorrect as it includes Pericardium instead of Myocardium.
C is incorrect as it switches the positions of Myocardium and Epicardium.
D is incorrect as it has the layers listed in the wrong order and includes Pericardium as the innermost layer.
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The nurse is giving a client an IV bolus of heparin. What is the most important nursing action?
- A. Monitor the client's heart rate.
- B. Check the client's blood pressure.
- C. Check for signs of bleeding.
- D. Monitor the client's respiratory rate.
Correct Answer: A
Rationale: The correct answer is A: Monitor the client's heart rate. When administering an IV bolus of heparin, it is crucial to monitor the client's heart rate because heparin can cause serious side effects such as bleeding and heparin-induced thrombocytopenia, which can lead to changes in heart rate. Checking blood pressure (B) is also important but not as critical as monitoring heart rate. Checking for signs of bleeding (C) is necessary but should be done after monitoring the heart rate. Monitoring the client's respiratory rate (D) is not directly related to heparin administration.
What is the condition where the body's immune system attacks its tissues, causing inflammation and damage?
- A. Autoimmune disease
- B. Infectious disease
- C. Allergic reaction
- D. Degenerative disease
Correct Answer: A
Rationale: The correct answer is A: Autoimmune disease. In autoimmune diseases, the immune system mistakenly attacks the body's tissues, leading to inflammation and damage. This occurs due to a breakdown in immune tolerance, resulting in the immune system targeting self-antigens. This leads to chronic inflammation and tissue damage. In contrast, infectious diseases are caused by pathogens, allergic reactions are responses to harmless substances, and degenerative diseases involve the gradual deterioration of tissues over time. Therefore, autoimmune disease best fits the description provided in the question.
A long-term-care resident with venous stasis ulcers is treated with Unna's boot. Which of the nursing activities included in the resident's care is best for you to delegate to a nursing assistant?
- A. Monitor capillary perfusion once every 8 hours.
- B. Teach family members the signs of infection.
- C. Evaluate foot sensation and movement each shift.
- D. Assist patient with cleaning around Unna's boot.
Correct Answer: D
Rationale: Cleaning around the boot is a simple task suitable for a nursing assistant.
Which term refers to the contraction phase of the heart when blood is ejected from the chambers?
- A. Systole
- B. Diastole
- C. Contractility
- D. Afterload
Correct Answer: A
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In the patient with chest pain, which results can differentiate unstable angina from an MI?
- A. ECG changes present at the onset of the pain
- B. A chest x-ray indicating left ventricular hypertrophy
- C. Appearance of troponin in the blood 48 hours after the infarct
- D. Creatine kinase (CK)-MB enzyme elevations that peak 18 hours after the infarct
Correct Answer: A
Rationale: ECG changes distinguish unstable angina from MI.