Nokea
The nurse is caring for a client who had a myocardial infarction yesterday and received alteplase (tPA). The client's spouse asks the nurse why that medication was given. What should the nurse include when replying?
- A. Alteplase (tPA) is given to relieve the pain of a heart attack.
- B. Alteplase (tPA) dissolves the clot that is blocking a coronary artery.
- C. Alteplase (tPA) prevents new clots from forming and existing clots from getting bigger.
- D. Alteplase (tPA) helps the heart muscle to repair itself.
Correct Answer: B
Rationale: Alteplase (tPA) is a thrombolytic drug and dissolves the clot that is blocking a coronary artery. It does not relieve pain, prevent new clots from forming, or help the heart muscle to heal.
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The nurse is performing in-service education about the use of the defibrillator.
Which of the following statements, if made by the nurse, is MOST important?
- A. Do not touch the bed when using the defibrillator.
- B. Check the defibrillator every 24 hours.
- C. Do not leave the defibrillator plugged in.
- D. Do not place the paddles over the electrodes.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-is a priority to prevent accidental countershock (2) equipment should be checked every eight hours (3) equipment should remain plugged in at all times (4) is not a priority; while this should not occur, it can be safely done
Which of the following statements best describes the gross motor development of a 2-year old?
- A. She skips without falling.
- B. She walks up and down stairs.
- C. She rides a tricycle.
- D. She is able to broad jump.
Correct Answer: B
Rationale: A 2-year-old can typically walk up and down stairs with support, a key gross motor milestone. Skipping , riding a tricycle , and broad jumping are skills developed later, around 3-5 years.
The home health nurse visits a client who is six-weeks postpartum.
- A. Which symptom reported by a six-week postpartum client warrants immediate follow-up?
- B. Occasional hot flashes.
- C. A pinkish vaginal discharge.
- D. Painful sexual intercourse.
- E. Feelings of fatigue.
Correct Answer: C
Rationale: Painful sexual intercourse six weeks postpartum is abnormal and may indicate infection, episiotomy complications, or other issues requiring immediate evaluation. Hot flashes, pinkish discharge, and fatigue are common during the postpartum period as the body recovers.
The nurse is teaching a client with a new diagnosis of type 2 diabetes about metformin (Glucophage). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication with meals.
- B. I should report nausea to my doctor.
- C. I should avoid drinking alcohol.
- D. I should stop this medication if my blood sugar is normal.
Correct Answer: D
Rationale: Stopping metformin when blood sugar is normal is incorrect, as type 2 diabetes requires ongoing treatment to maintain control. Options A, B, and C are correct: taking with meals reduces GI upset, nausea is a side effect, and alcohol increases lactic acidosis risk.
The nurse is caring for a client who is receiving a continuous IV infusion of nitroglycerin for chest pain. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 100/60 mmHg
- B. Heart rate of 80 bpm
- C. Respiratory rate of 18 breaths/min
- D. Oxygen saturation of 95%
Correct Answer: A
Rationale: Hypotension (100/60 mmHg) is a serious nitroglycerin side effect, risking inadequate perfusion. Options B, C, and D are normal findings.