Nokea
The nurse is caring for a client with a suspected myocardial infarction. Which of the following actions should the nurse perform FIRST?
- A. Administer aspirin 325 mg PO.
- B. Apply oxygen at 2 L/min via nasal cannula.
- C. Obtain a 12-lead ECG.
- D. Start an IV line.
Correct Answer: B
Rationale: Applying oxygen is the priority to improve myocardial oxygenation in a suspected myocardial infarction, addressing the immediate threat of hypoxia. Options A, C, and D are important but secondary: aspirin prevents clot progression, ECG confirms diagnosis, and IV access supports medication delivery.
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The nurse is caring for a client with possible cervical cancer. What clinical data would the nurse most expect to find in the client's history?
- A. Postcoital vaginal bleeding
- B. Nausea and vomiting
- C. Foul-smelling vaginal discharge
- D. Hyperthermia
Correct Answer: A
Rationale: Postcoital vaginal bleeding is a hallmark symptom of cervical cancer due to tumor involvement of the cervix. Nausea, vomiting, foul-smelling discharge, and hyperthermia may occur in advanced stages or infections but are less specific, so B, C, and D are incorrect.
A nurse is teaching a client about self-administration of Haldol 15 mg po hs. For which side effect/s must the client seek medical attention?
- A. SOB and fatigue
- B. restlessness and muscle spasms
- C. dry mouth
- D. diarrhea
Correct Answer: B
Rationale: Muscle spasms and restlessness are side effects of Haldol.
A 10-year-old child is admitted to the hospital with injuries. Which finding most suggests that additional assessment for child abuse is indicated?
- A. The child asks to have friends visit.
- B. The child asks to have a teacher bring in homework.
- C. The child's parents state that they need to spend some time with the child's siblings.
- D. The child's parents will not leave the child alone while in the hospital.
Correct Answer: D
Rationale: Constant parental presence may indicate control or fear of the child disclosing abuse, warranting further abuse assessment.
A client has received an IV antibiotic every eight hours for four days.
- A. Which finding would cause the nurse to be concerned about postinfusion phlebitis in a client receiving IV antibiotics?
- B. Tenderness at the IV site.
- C. Increased swelling at the insertion site.
- D. Reddened area or red streaks at the site.
- E. Leaking of fluid around the IV catheter.
Correct Answer: C
Rationale: Postinfusion phlebitis is characterized by inflammation, with reddened areas or streaks along the vein. Tenderness is common, swelling suggests infiltration, and leaking indicates poor catheter placement, but redness is the hallmark of phlebitis.
The physician diagnoses Graves' disease for a 28-year-old woman seen in the clinic. The nurse would expect the client to exhibit which of the following symptoms?
- A. Lethargy in the early morning.
- B. Sensitivity to cold.
- C. Weight loss of 10 lb in 3 weeks.
- D. Reduced deep tendon reflexes.
Correct Answer: C
Rationale: increased metabolic rate causes weight loss even with increased appetite