Nokea
What is the priority intervention for a patient with a suspected myocardial infarction (MI)?
- A. Administering oxygen.
- B. Administering nitroglycerin.
- C. Administering aspirin.
- D. Administering morphine.
Correct Answer: A
Rationale: Administering oxygen is the priority intervention for a patient with a suspected myocardial infarction to improve oxygenation. Oxygen helps ensure an adequate oxygen supply to the heart muscle, reducing the workload on the heart. Nitroglycerin and aspirin are important interventions in the treatment of MI; however, oxygen administration takes precedence to ensure adequate oxygenation. Morphine may be considered for pain relief, but it is not the initial priority in the treatment of a suspected MI.
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Which of the following is a key symptom of appendicitis?
- A. Right lower quadrant pain.
- B. Left lower quadrant pain.
- C. Generalized abdominal pain.
- D. Rebound tenderness.
Correct Answer: A
Rationale: Corrected Choice A: Right lower quadrant pain is a classic and key symptom of appendicitis. Pain in the right lower quadrant is typically the initial symptom and is a result of inflammation and irritation of the appendix. This pain can start around the umbilicus and then migrate to the right lower quadrant. It is important to note that appendicitis rarely presents with pain in the left lower quadrant or generalized abdominal pain. Rebound tenderness, indicated in Choice D, is a sign of peritoneal irritation and is associated with appendicitis, but it is not as characteristic as the right lower quadrant pain in the initial presentation of appendicitis.
In a patient with pneumonia, what is the primary goal of treatment?
- A. Reducing inflammation.
- B. Eliminating the infection.
- C. Reducing pain.
- D. Preventing complications.
Correct Answer: B
Rationale: The primary goal of treating pneumonia is to eliminate the infection. Antibiotics are commonly used to target the specific pathogen causing pneumonia. While reducing inflammation and preventing complications are important aspects of treatment, the key focus initially is on eradicating the infectious agent to improve the patient's condition and prevent further spread of the infection.
In a patient with cirrhosis, which of the following lab results is most concerning?
- A. Elevated liver enzymes.
- B. Low albumin levels.
- C. Elevated bilirubin levels.
- D. Low platelet count.
Correct Answer: D
Rationale: In a patient with cirrhosis, a low platelet count is the most concerning lab result. Thrombocytopenia, or low platelet count, is common in cirrhosis due to impaired platelet production in the liver. It significantly increases the risk of bleeding and can lead to serious complications such as hemorrhage. Elevated liver enzymes (Choice A) are expected in cirrhosis but may not directly indicate the severity of the disease. Low albumin levels (Choice B) are common in cirrhosis and can contribute to fluid retention but do not pose an immediate risk of bleeding. Elevated bilirubin levels (Choice C) are also expected in cirrhosis and typically indicate impaired liver function but do not directly increase the risk of bleeding as much as a low platelet count.
A client with peripheral arterial disease (PAD) has cool and pale feet with diminished pulses. Which of the following interventions should the nurse implement?
- A. Keep the legs elevated above the level of the heart.
- B. Encourage the client to exercise daily.
- C. Apply warm compresses to the affected area.
- D. Apply ice packs to the affected area.
Correct Answer: C
Rationale: In peripheral arterial disease (PAD), there is decreased blood flow to the extremities. Applying warm compresses helps dilate blood vessels, improve circulation, and relieve symptoms. Elevating the legs above the heart level may further compromise blood flow. Encouraging daily exercise is important in PAD management but may not be appropriate when the client has cool, pale feet with diminished pulses. Applying ice packs can worsen vasoconstriction and further reduce blood flow, exacerbating symptoms in PAD.
A client with chronic renal failure is being treated with sodium polystyrene sulfonate (Kayexalate). The nurse should monitor the client for which of the following?
- A. Hyponatremia.
- B. Hypokalemia.
- C. Hyperkalemia.
- D. Hypocalcemia.
Correct Answer: C
Rationale: The correct answer is C: Hyperkalemia. Sodium polystyrene sulfonate (Kayexalate) is used to treat high potassium levels (hyperkalemia) by exchanging sodium ions for potassium ions in the large intestine, which is then eliminated through the feces. Therefore, the nurse should monitor the client for changes in potassium levels to ensure the effectiveness of the treatment. Choices A, B, and D are incorrect because sodium polystyrene sulfonate (Kayexalate) is not associated with causing hyponatremia, hypokalemia, or hypocalcemia.