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The nurse is teaching a client with dysrhythmia about the electrical pathway of an impulse as it travels through the heart. Which of these demonstrates the normal pathway?
- A. AV node, SA node, Bundle of His, Purkinje fibers.
- B. Purkinje fibers, SA node, AV node, Bundle of His.
- C. Bundle of His, Purkinje fibers, SA node , AV node.
- D. SA node, AV node, Bundle of His, Purkinje fibers.
Correct Answer: D
Rationale: The normal conduction pathway starts at the SA node.
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What nursing action is most important initially for Ms. Jenkins with pneumococcal pneumonia?
- A. Administer humidified oxygen, as ordered
- B. Obtain an order for aspirin
- C. Auscultate the posterior basal segments for rales and rhonchi
- D. Explain the diagnosis to the patient
Correct Answer: A
Rationale: Oxygen therapy addresses hypoxemia, a primary concern in pneumonia.
A healthcare professional is assessing a client who has a new onset of confusion. Which laboratory value should the professional check first?
- A. Blood glucose level
- B. Serum sodium level
- C. Serum calcium level
- D. Blood urea nitrogen (BUN)
Correct Answer: A
Rationale: The correct answer is A: Blood glucose level. The healthcare professional should check the blood glucose level first because hypoglycemia or hyperglycemia can cause confusion. Hypoglycemia can lead to altered mental status quickly and should be ruled out immediately. Checking the serum sodium level (B), serum calcium level (C), or blood urea nitrogen (D) can be important in further assessment, but addressing the blood glucose level is the primary concern in this scenario to rule out any immediate life-threatening conditions related to glucose imbalance.
Persons at risk are the target population for cancer screening programs. Which asymptomatic patient(s) needs extra encouragement to participate in cancer screening? (Choose all that apply.)
- A. A 19-year-old white-American female who is sexually inactive for a Pap smear.
- B. A 35-year-old white-American female for an annual mammogram.
- C. A 45-year-old African-American male for an annual prostate-specific antigen.
- D. A 49-year-old African-American male for an annual fecal occult blood test.
Correct Answer: D
Rationale: African-American males are at higher risk for prostate and colorectal cancers, making regular screening crucial for early detection.
The joints most commonly involved with rheumatoid arthritis include the
- A. Spine, from the sacrum to the cervical spine.
- B. Symmetrical involvement of major joints.
- C. Small joints of hands and feet.
- D. Slightly movable joints of the axial skeleton.
Correct Answer: C
Rationale: RA primarily affects small joints symmetrically.
The nurse knows that a patient taught sleep hygiene practices needs further instruction when he says
- A. Once I go to bed, I should get up if I am not asleep after 20 minutes.
- B. It’s okay to have my usual two glasses of wine in the evening before bed.
- C. A couple of crackers with cheese and a glass of milk may help to relax before bed.
- D. I should go to the gym earlier in the day so that I’m done at least 6 hours before bedtime.
Correct Answer: B
Rationale: The correct answer is B. Alcohol disrupts sleep architecture, making it counterproductive for sleep hygiene. Getting up after 20 minutes (A) is a recommended practice, and exercising early (D) promotes better sleep.