Nokea
The nurse is caring for a client post-myocardial infarction. Which activity should the nurse encourage to promote recovery?
- A. Bed rest for 48 hours
- B. Light ambulation as tolerated
- C. Heavy lifting after 24 hours
- D. High-intensity exercise
Correct Answer: B
Rationale: Light ambulation as tolerated promotes circulation and prevents complications like deep vein thrombosis, while avoiding overexertion post-myocardial infarction.
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Which statement about automated external defibrillators is accurate?
- A. They are not as effective as regular defibrillators.
- B. They are replacing regular defibrillators in acute care settings.
- C. Only BLS certified people in the community should use them.
- D. They can be easily used by people with no healthcare experience.
Correct Answer: D
Rationale: AEDs are designed for use by laypersons with minimal training, making them accessible for public use in emergencies.
A client with a history of type 1 diabetes is admitted with diabetic ketoacidosis. The nurse should prioritize which of the following interventions?
- A. Administer regular insulin intravenously.
- B. Administer potassium supplements.
- C. Restrict fluid intake.
- D. Administer sodium bicarbonate.
Correct Answer: A
Rationale: Intravenous regular insulin is the priority to lower blood glucose and halt ketogenesis in diabetic ketoacidosis.
The nurse is teaching a client with a new diagnosis of asthma about the use of a peak flow meter. Which of the following instructions is most important?
- A. Use the meter once a week.
- B. Record the highest of three readings.
- C. Clean the meter with soap daily.
- D. Use the meter only during an asthma attack.
Correct Answer: B
Rationale: Recording the highest of three readings provides an accurate measure of peak expiratory flow to monitor asthma control.
What is the purpose of administering diphenhydramine before a blood transfusion?
- A. To prevent urticaria
- B. To avoid fever and chills
- C. To enhance clotting factors
- D. To expand the blood volume
Correct Answer: A
Rationale: The clinical indicators of urticaria are a rash accompanied by pruritus. Urticaria is a manifestation of a transfusion reaction when it occurs during a blood transfusion and is preventable by premedicating the client with an antihistamine, such as diphenhydramine. The remaining options are incorrect. Clients can also be premedicated with acetaminophen to help prevent fever and chills.
Which of the following is considered an internal disaster?
- A. A tornado that has touched down on the healthcare facility
- B. A severe cyclone that has destroyed nearby homes
- C. A massive train accident that brings victims to your facility
- D. An act of bioterrorism in a nearby factory
Correct Answer: A
Rationale: An internal disaster is an event within the healthcare facility, such as a tornado directly affecting it, requiring internal emergency protocols.