Nokea
When teaching the client with myocardial infarction (MI), the nurse explains that the pain associated with MI is caused by:
- A. Left ventricular overload.
- B. Impending circulatory collapse.
- C. Extracellular electrolyte imbalances.
- D. Insufficient oxygen reaching the heart muscle.
Correct Answer: D
Rationale: MI pain results from myocardial ischemia due to insufficient oxygen delivery to the heart muscle, caused by coronary artery occlusion.
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The nurse is assessing a client with a casted arm for signs of infection. Which finding is most concerning?
- A. Mild itching under the cast.
- B. Foul odor from the cast.
- C. Warmth at the cast edges.
- D. Slight swelling of fingers.
Correct Answer: B
Rationale: A foul odor from the cast suggests infection, requiring immediate evaluation.
A client has had a nasogastric tube connected to low intermittent suction. The client is at risk for which of the following complications?
- A. Confusion.
- B. Muscle cramping.
- C. Edema.
- D. Tremors.
Correct Answer: B
Rationale: Nasogastric suction can cause electrolyte imbalances, such as hypokalemia, leading to muscle cramping due to loss of potassium-rich gastric fluid.
Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence?
- A. Limit fluid intake to 1,000 mL/day.
- B. Insert an indwelling urinary catheter.
- C. Establish a regular voiding schedule.
- D. Administer prophylactic antibiotics, as ordered.
Correct Answer: C
Rationale: A regular voiding schedule helps manage incontinence by promoting bladder emptying before urgency. Fluid restriction risks dehydration, indwelling catheters increase infection risk, and antibiotics are not preventive for incontinence.
Thirty-two children are brought to the emergency department after a school bus accident. Two children were killed along with the three people in the car that caused the crash. Before the victims arrive, in addition to ensuring that the hospital staff are prepared for the emergency, which step should the nurse anticipate carrying out?
- A. Calling the nearest crisis response team.
- B. Alerting the news media.
- C. Notifying the hospital volunteer office.
- D. Calling the school to inform teachers of the accident.
Correct Answer: A
Rationale: A crisis response team is essential to provide psychological support to victims, families, and staff following a traumatic event like a school bus accident with fatalities.
The client with a laryngectomy is being discharged. The nurse should determine that the client understands to do which of the following self-care measures? Select all that apply.
- A. Provide humidification in the home.
- B. Use a protective shield over the stoma for bathing.
- C. Consume a liberal intake of fluids (2 to 3 L/day).
- D. Limit spicy seasonings on food.
- E. Follow a low-fiber diet.
Correct Answer: A,B,C
Rationale: Self-care measures include home humidification to keep the airway moist, using a stoma shield during bathing to prevent water entry, and consuming 2-3 L/day of fluids to maintain hydration. Spicy foods and low-fiber diets are not typically restricted.