Nokea
The nurse is caring for a client post-myocardial infarction on the cardiac unit. The client is exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?
- A. BP 90/60
- B. Chest pain
- C. Increased anxiety
- D. Temp 98.6°F
Correct Answer: B
Rationale: Chest pain is a hallmark of cardiogenic shock due to myocardial ischemia, distinguishing it from anaphylactic shock, which typically involves urticaria or bronchospasm. Low BP (A) and anxiety (C) are common in both, and normal temperature (D) is nonspecific.
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The client is prescribed digoxin (Lanoxin) for heart failure. Which instruction should the nurse include in the teaching plan?
- A. Take the medication with meals to prevent nausea.'
- B. Report a pulse below 60 beats per minute.'
- C. Increase potassium-rich foods in your diet.'
- D. Take an extra dose if you miss one.'
Correct Answer: B
Rationale: Digoxin toxicity is increased with bradycardia, so a pulse below 60 beats per minute should be reported. It can be taken with or without food, potassium monitoring is important but not increasing, and extra doses are dangerous.
A client receiving Vancocin (vancomycin) has a serum level of 20 mcg/mL. The nurse knows that the therapeutic range for vancomycin is:
- A. 5-10 mcg/mL
- B. 10-25 mcg/mL
- C. 25-40 mcg/mL
- D. 40-60 mcg/mL
Correct Answer: B
Rationale: The therapeutic range for vancomycin is 10-25 mcg/mL, ensuring effective treatment of infections while minimizing toxicity risks.
The client is admitted with a diagnosis of bacterial meningitis. Which precaution should the nurse implement?
- A. Standard precautions
- B. Droplet precautions
- C. Contact precautions
- D. Airborne precautions
Correct Answer: B
Rationale: Bacterial meningitis (e.g., Neisseria meningitidis) is transmitted via respiratory droplets, requiring droplet precautions. Standard, contact, and airborne precautions are not appropriate.
The nurse is caring for a client with a cerebrovascular accident (CVA) who is complaining of being nauseated and is requesting an emesis basin. Which action would the nurse take first?
- A. Administer an ordered antiemetic.
- B. Obtain an ice bag and apply to the client's throat.
- C. Turn the client to one side.
- D. Notify the physician.
Correct Answer: C
Rationale: Turning the client to one side prevents aspiration, a priority in a nauseated CVA client with potential swallowing deficits. Administering an antiemetic (A) or notifying the physician (D) is secondary, and ice (B) is ineffective.
The nurse is making room assignments for four obstetrical clients. If only one private room is available, it should be assigned to:
- A. A multigravida with diabetes mellitus
- B. A primigravida with preeclampsia
- C. A multigravida with preterm labor
- D. A primigravida with hyperemesis gravidarum
Correct Answer: B
Rationale: Preeclampsia requires close monitoring due to risks like seizures or stroke, making a private room essential for a primigravida with this condition.