Nokea
When the nurse is obtaining this client's health history, which question about pain is least helpful?
- A. How long have you been in pain?
- B. Where is your pain located?
- C. What were you doing when your pain started?
- D. What medications do you take for pain?
Correct Answer: D
Rationale: Asking about pain medications is less critical in the acute MI setting compared to timing, location, and triggers, which guide diagnosis and urgency.
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Which nursing action is most appropriate to perform next?
- A. The nurse notifies the physician, requesting a hypnotic or sedative.
- B. The nurse provides a video of the surgery for the client to watch.
- C. The nurse waits until the client's spouse is present to excessive the surgery.
- D. The nurse listens as the client talks about fears concerning surgery and rehabilitation.
Correct Answer: D
Rationale: Listening to the client's fears reduces anxiety and supports emotional preparation for surgery.
The nurse is observing a client who is learning to perform Buerger-Allen exercises. The nurse knows that the client is performing these exercises correctly when the client is observed doing what?
- A. Alternately dorsiflexing and plantar flexing the feet while the legs are elevated
- B. Massaging the legs beginning at the feet and moving toward the heart
- C. Alternately walking short distances and resting with the legs elevated
- D. Elevating the legs, then dangling them, and then lying flat for three minutes in each position
Correct Answer: D
Rationale: Buerger-Allen exercises involve elevating the legs to promote arterial emptying, dangling to promote filling, and lying flat to rest, performed in cycles to improve circulation.
Which response by the nurse is most accurate?
- A. Sustained hypertension decreases thenvim life span of many blood cells.
- B. Sustained hypertension leads to the formation of venous blood clots.
- C. Sustained hypertension compromises blood flow to many vital organs.
- D. Sustained hypertension predisposes to narrowing of the cardiac valves.
Correct Answer: C
Rationale: Sustained hypertension increases vascular resistance, which can compromise blood flow to vital organs like the heart, brain, and kidneys, leading to organ damage.
Which value should the nurse report immediately to the physician?
- A. Sodium: 137 mEq/L
- B. Potassium: 2.5 mEq/L
- C. Chloride: 97 mEq/L
- D. Bicarbonate: 25 mEq/L
Correct Answer: B
Rationale: Potassium of 2.5 mEq/L (hypokalemia) is critical, especially with diuretics, risking arrhythmias.
A client has an elevated AST 24 hours following chest pain and shortness of breath. This is suggestive of which of the following?
- A. Gallbladder disease
- B. Liver disease
- C. Myocardial infarction
- D. Skeletal muscle injury
Correct Answer: C
Rationale: AST is an enzyme released in response to tissue damage. The symptoms of chest pain and shortness of breath, along with elevated AST 24 hours later, are suggestive of myocardial infarction. AST rises after a myocardial infarction but may also rise with liver damage or skeletal muscle injury. Gallbladder disease typically presents with pain in the right scapula region and would not have an elevated AST.