Nokea
The nurse needs to be aware that the most common early complication of a myocardial infarction is:
- A. Diabetes mellitus
- B. Anaphylactic shock
- C. Cardiac hypertrophy
- D. Cardiac dysrhythmia
Correct Answer: D
Rationale: Myocardial infarction causes tissue damage, which may interrupt electrical impulses. Myocardial irritability results from lack of oxygenated tissue.
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The nurse is caring for a client with leukemia who is receiving the drug doxorubicin (Adriamycin). Which toxic effects of this drug would be reported to the physician immediately?
- A. Rales and distended neck veins
- B. Red discoloration of the urine
- C. Nausea and vomiting
- D. Elevated BUN and dry, flaky skin
Correct Answer: A
Rationale: Rales and distended neck veins suggest cardiotoxicity (e.g., heart failure), a serious doxorubicin side effect requiring immediate reporting. Red urine (B) is expected, nausea/vomiting (C) are common, and BUN/skin changes (D) are less urgent.
A client admitted to the psychiatric unit claims to be the Pope and insists that he will not be kept away from his followers. The most likely explanation for the client's delusion is:
- A. A reaction formation
- B. A stressful event
- C. Low self-esteem
- D. Overwhelming anxiety
Correct Answer: C
Rationale: Delusions of grandeur, like claiming to be the Pope, often stem from low self-esteem in psychiatric disorders like schizophrenia, compensating for feelings of inadequacy. The other factors are less specific.
The nurse is caring for a client with a history of diverticulitis. Which meal selection indicates that the client understands the dietary teaching?
- A. Roast beef, mashed potatoes, and spinach
- B. Baked chicken, rice, and an apple
- C. Ham sandwich, chips, and whole wheat bread
- D. Spaghetti with meat sauce and garlic bread
Correct Answer: B
Rationale: Clients with diverticulitis should follow a low-residue diet during flare-ups to reduce bowel irritation. Baked chicken, rice, and an apple are low in fiber and suitable. The other options contain high-fiber or irritating foods (e.g., spinach, whole wheat, garlic).
A client is diagnosed with diabetic ketoacidosis. The nurse should be prepared to administer which of the following IV solutions?
- A. D5 in normal saline
- B. D5W
- C. 0.9 normal saline
- D. D5 in lactated Ringer's
Correct Answer: C
Rationale: A concentration of 0.9 NS is used to correct extracellular fluid depletion.
The nurse is caring for a client in labor. The fetal monitor shows early decelerations. The nurse should:
- A. Notify the physician immediately
- B. Reposition the client to her left side
- C. Continue to monitor the fetal heart rate
- D. Administer oxygen at 8-10 liters per minute
Correct Answer: C
Rationale: Early decelerations are benign caused by fetal head compression during contractions and do not indicate fetal distress. Continuing to monitor the fetal heart rate is appropriate. Repositioning oxygen or notifying the physician are unnecessary unless other abnormalities occur.