Nokea
The nurse receives information about the assigned patients during shift report. Which patient would the nurse assess first?
- A. A patient who reports dizziness with a blood pressure (BP) of 150/92 mm Hg.
- B. A patient who reports a severe headache and has begun vomiting.
- C. A patient with a hip fracture who reports a pain level of 2 on a 1-to-10 scale.
- D. A patient who received an angiotensin-converting enzyme (ACE) inhibitor 30 minutes previously and reports fatigue.
Correct Answer: B
Rationale: A severe headache and vomiting could be indicative of a serious neurological condition such as a stroke, intracranial bleeding, or increased intracranial pressure. This patient needs urgent assessment and intervention to prevent potential complications.
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Which information would the nurse include when discussing pain due to chronic stable angina with the patient?
- A. Occurs with both activity and rest.
- B. Generally lasts 10-15 minutes or more.
- C. Does not subside when the precipitating factor is resolved.
- D. Occurs intermittently over a period of time in a similar pattern.
Correct Answer: D
Rationale: Chronic stable angina occurs intermittently in a predictable pattern, triggered by exertion and relieved by rest or nitroglycerin.
The nurse is teaching a patient about the administration of liquid iron supplements. Which response by the patient indicates the need for additional teaching?
- A. I will take my iron supplement with a straw.
- B. I will take my iron supplement at bedtime.
- C. I will take my iron supplement along with meals.
- D. I will take my iron supplement along with orange juice.
Correct Answer: C
Rationale: Taking iron supplements with meals decreases absorption, indicating a need for further teaching; iron should be taken on an empty stomach or with vitamin C.
A patient who smokes reports chest pain while at rest. Which condition would the nurse suspect the patient is experiencing?
- A. Silent ischemia.
- B. Angina decubitus.
- C. Prinzmetal angina.
- D. Chronic stable angina.
Correct Answer: C
Rationale: Prinzmetal angina, also known as variant angina, typically occurs at rest due to coronary artery spasms, which aligns with the patient's symptoms of chest pain at rest.
Which role is attributed to the base in the acid-base balance?
- A. Does not interact with acids.
- B. Promotes the excretion of acid.
- C. Activates the system of acid-base balance.
- D. Increases the action of the hydrogen ions.
Correct Answer: B
Rationale: Bases, like bicarbonate, promote acid excretion by neutralizing hydrogen ions, aiding in maintaining acid-base balance.
Which laboratory report finding would support the nurse's conclusion that a patient has thalassemia major? Select all that apply.
- A. Increased bilirubin levels.
- B. Increased reticulocyte level.
- C. Increased mean corpuscular volume.
- D. Increased total iron-binding capacity.
Correct Answer: A,B,D
Rationale: Increased bilirubin, reticulocyte levels, and total iron-binding capacity are seen in thalassemia major due to hemolysis, bone marrow response, and increased iron absorption.