Nokea
The most common complication following a myocardial infarction is:
- A. Hyperkalemia
- B. Cardiac dysrhythmia
- C. Acute respiratory distress
- D. Hypovolemic shock
Correct Answer: B
Rationale: Cardiac dysrhythmias are the most common complication post-myocardial infarction due to ischemic changes affecting the heart's electrical conduction.
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The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?
- A. Apply dressing using sterile technique
- B. Improve the client's nutrition status
- C. Initiate limb elevation and compression
- D. Begin proteolytic debridement
Correct Answer: B
Rationale: The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other interventions are appropriate, but without proper nutrition, they would be of little help.
The nurse in the emergency department is caring for a client who sustained blunt force head trauma and is experiencing blurry vision. The nurse should suspect the client has sustained injury to the
- A. temporal lobe
- B. occipital lobe
- C. parietal lobe
- D. frontal lobe
Correct Answer: B
Rationale: Blurry vision post-head trauma suggests injury to the occipital lobe , which processes visual information. Temporal , parietal , and frontal lobes manage other functions.
The nursing care plan for a client with decreased adrenal function should include
- A. Encouraging activity
- B. Placing client in reverse isolation
- C. Limiting visitors
- D. Measures to prevent constipation
Correct Answer: C
Rationale: Limiting visitors. Limiting visitors reduces physical and emotional exertion, preventing an Addisonian crisis.
A nurse is caring for a child who is receiving oxygen at 2 L/min by nasal cannula and observes the current oxygen saturation and pulse plethysmographic waveform on the pulse oximeter. Which intervention should be the nurse's initial action?
- A. Auscultate the child's lung fields
- B. Have the child take slow, deep breaths
- C. Increase the oxygen flow rate to 3 L/min
- D. Verify the position and integrity of the finger probe
Correct Answer: D
Rationale: An inaccurate pulse oximeter reading may result from a poorly positioned probe. Verifying the probe's position is the initial action. Auscultation , deep breaths , or increasing oxygen are secondary without confirming the reading.
The client is scheduled for a paracentesis. What should the nurse expect to do prior to the procedure?
- A. Insert an indwelling catheter
- B. Have the client void
- C. Keep the client NPO
- D. Administer an enema
Correct Answer: B
Rationale: Having the client void before paracentesis prevents bladder puncture during the procedure. Catheter insertion, NPO status, or enemas are not typically required.