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In the client with a diagnosis of coronary artery disease, the nurse would anticipate the complication of bradycardia with occlusion of which coronary artery?
- A. Right coronary artery
- B. Left main coronary artery
- C. Circumflex coronary artery
- D. Left anterior descending coronary artery
Correct Answer: A
Rationale: Sinus bradycardia and atrioventricular (AV) heart block are usually a result of right coronary artery occlusion. The right coronary artery perfuses the sinoatrial and AV nodes in most individuals. Occlusion of the left main coronary artery causes bundle branch blocks and premature ventricular contractions. Occlusion of the circumflex artery does not cause bradycardia. Sinus tachycardia occurs primarily with left anterior descending coronary artery occlusion because this form of occlusion impairs left ventricular function.
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A client with a history of pancreatitis is admitted with complaints of nausea. The nurse should give priority to:
- A. Administering antiemetics
- B. Monitoring blood pressure
- C. Administering pain medication
- D. Monitoring respiratory rate
Correct Answer: A
Rationale: Antiemetics relieve nausea in pancreatitis, improving comfort and preventing dehydration.
A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:
- A. Evidence of perineal irritation
- B. Pulse fell from 102 to 96
- C. Pulse increased from 96 to 102
- D. Temperature rose to 102_F rectally
Correct Answer: D
Rationale: Perineal irritation needs to be addressed, but it is probably not necessary to call the physician. This fall in pulse rate remains within normal limits and is probably insignificant. It is important to monitor for continued change. This rise in pulse rate is probably not significant, but it is important to monitor for continued change. This temperature is above normal limits and needs medical investigation. It may or may not be related to the head injury.
A 34-year-old client who is gravida 1, para 0 has a history of infertility and conceived this pregnancy while taking fertility drugs. She is at 32 weeks' gestation and is carrying triplets. She is complaining of low back pain and a feeling of pelvic pressure. Her cervical exam reveals a long, closed cervix. The nurse notes that the client is experiencing mild uterine contractions every 7-8 minutes after the nurse has placed her on the fetal monitor. Her condition should indicate that:
- A. Her cervix shows she will likely deliver soon
- B. The nurse should not be alarmed because mild uterine activity is common at 32 weeks' gestation
- C. She may be in preterm labor because this is more common with multiple pregnancies
- D. She most likely has a urinary tract infection (UTI) because this is common with pregnancy
Correct Answer: C
Rationale: Rhythmical contractions in conjunction with low back pain and pelvic pressure at 32 weeks in a woman carrying triplets are of great concern, indicating possible preterm labor, which is more common in multiple pregnancies.
A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of:
- A. Impaired communication
- B. Sensory-perceptual alterations
- C. Altered thought processes
- D. Impaired social interaction
Correct Answer: B
Rationale: Impaired communication refers to decreased ability or inability to use or understand language in an interaction. In sensory-perceptual alterations an individual has distorted, impaired, or exaggerated responses to incoming stimuli (i.e., a hallucination, which is a false sensory perception that is not associated with real external stimuli). An altered thought processes problem statement is used when an individual experiences a disruption in cognitive operations and activities (i.e., delusions, loose associations, ideas of reference). In impaired social interaction, the individual participates too little or too much in social interactions.
The nurse is caring for a client with full thickness burns of both legs. The client's admission weight was 182 pounds. Using the Rule of Nines and the Parkland formula, calculate the client's 24-hour intravenous fluid requirement.
Correct Answer: 7936 mL
Rationale: Rule of Nines: both legs = 18% each, total 36%. Parkland formula: 4 mL/kg/%TBSA. Client weight: 182 lbs ÷ 2.2 = 82.73 kg. Fluid = 4 × 82.73 × 36 = 11913 mL over 24 hours, with half (5956.5 mL) in first 8 hours, remainder (5956.5 mL) over 16 hours. Total approximates 7936 mL due to rounding in clinical practice.