Nokea
Upon hearing that he has acute pericarditis, the patient asks how he could have contracted the disease. The best response is
- A. The upper respiratory viral infection that you experienced a couple of weeks ago could have led to acute pericarditis.
- B. It is a genetic condition that you received from your father.
- C. It is a genetic condition that you received from your mother.
- D. It is the weakening of the left side of your heart.
Correct Answer: A
Rationale: Viral infections are a common cause of acute pericarditis.
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To prepare a patient on the unit for a bronchoscopic procedure, the medical-surgical nurse administers an IV sedative. The nurse then instructs the licensed practical nurse to
- A. educate the patient about the procedure.
- B. give the patient small sips of water only.
- C. measure the patient's blood pressure and heart rate.
- D. take the patient to the bathroom one more time.
Correct Answer: D
Rationale: Emptying the bladder before the procedure is important for comfort and safety.
To do an effective breast self-examination, when should the woman examine her breasts?
- A. During the fourth to the seventh menstrual cycle day
- B. Every other month
- C. While standing up
- D. 1 week before the menstrual cycle
Correct Answer: A
Rationale: The correct answer is A: During the fourth to the seventh menstrual cycle day. This is because breasts are least likely to be swollen or tender during this time, allowing for a more accurate examination. Choice B is incorrect as regular monthly examinations are recommended. Choice C can be done while standing up or lying down. Choice D is incorrect as breasts may be more tender and swollen closer to the menstrual cycle, making it harder to detect abnormalities.
Until Mr. Jones’ diagnosis is confirmed, what should be a priority?
- A. Encouraging rest
- B. Monitoring intake and output
- C. Preventing spread of infection to others
- D. Providing attractive meals
Correct Answer: C
Rationale: The correct answer is C: Preventing spread of infection to others. This is the priority because until Mr. Jones' diagnosis is confirmed, it is crucial to prevent potential transmission of any infectious diseases to others. Encouraging rest (choice A) and providing attractive meals (choice D) are important for overall well-being but not as critical as preventing the spread of infection. Monitoring intake and output (choice B) is important for assessing Mr. Jones' health status but does not directly address the potential risk of infecting others. Therefore, choice C is the most immediate priority to ensure the safety of others.
While caring for a client receiving positive-pressure mechanical ventilation, which intervention should the nurse NOT implement to prevent complications?
- A. Elevate the head of the bed to at least 30°.
- B. Verify the prescribed ventilator settings daily.
- C. Administer pantoprazole as prescribed.
- D. Reposition the endotracheal tube to the opposite side of the mouth daily.
Correct Answer: D
Rationale: The correct answer is D. Repositioning the endotracheal tube to the opposite side of the mouth daily is not necessary and could potentially lead to complications such as accidental extubation or damage to the airway. A: Elevating the head of the bed helps prevent aspiration. B: Verifying ventilator settings daily ensures proper functioning. C: Administering pantoprazole helps prevent stress ulcers. In summary, D is incorrect because it is unnecessary and poses risks, while A, B, and C are important interventions to prevent complications associated with positive-pressure mechanical ventilation.
A client is vomiting. Which of the following actions should the nurse take first?
- A. Provide the client with an emesis basin
- B. Notify housekeeping
- C. Prevent the client from aspirating
- D. Administer an antiemetic to the client
Correct Answer: C
Rationale: The correct action for the nurse to take first is to prevent the client from aspirating. Aspiration is a serious risk when a client is vomiting as it can lead to respiratory complications. The nurse should position the client on their side to prevent aspiration of vomitus into the airway. This immediate action takes priority over providing an emesis basin, notifying housekeeping, or administering an antiemetic, which do not address the urgent need to prevent aspiration.