Nokea
Which laboratory test would be the least effective in making the diagnosis of a myocardial infarction?
- A. AST
- B. Troponin
- C. CK-MB
- D. Myoglobin
Correct Answer: A
Rationale: AST is less specific for myocardial infarction than troponin, CK-MB, or myoglobin.
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The nurse on oncology is caring for a client with a white blood count of 600. During evening visitation, a visitor brings a potted plant. What action should the nurse take?
- A. Allow the client to keep the plant
- B. Place the plant by the window
- C. Water the plant for the client
- D. Tell the family members to take the plant home
Correct Answer: D
Rationale: A low WBC (neutropenia) increases infection risk, so the plant, which may harbor bacteria or fungi, should be removed.
The mother of a 2-year-old asks the nurse when she should schedule her son's first dental visit. The nurse's response is based on the knowledge that most children have all their deciduous teeth by:
- A. 15 months
- B. 18 months
- C. 24 months
- D. 30 months
Correct Answer: D
Rationale: Most children have all 20 deciduous teeth by 30 months, guiding the timing of the first dental visit.
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for:
- A. Maternal hypoglycemia
- B. Fetal bradycardia
- C. Maternal hyperreflexia
- D. Fetal movement
Correct Answer: B
Rationale: Pitocin can cause uterine hyperstimulation, leading to fetal bradycardia, which requires close monitoring.
The nurse finds that a client receiving digoxin (Lanoxin) 0.25 mg orally has an apical pulse of 54. Which of the following should the nurse do first?
- A. withhold the medicine and contact the prescribing physician
- B. ask another nurse to verify the apical pulse
- C. administer the medication and recheck the pulse in 30 minutes
- D. order a stat ECG
Correct Answer: A
Rationale: An apical pulse of 54 is below the safe threshold (typically 60) for digoxin, indicating potential toxicity. Withholding the dose and notifying the provider is the priority.
A client with prostate cancer has been given the option of various treatments and asks the nurse for advice. Which of the following is the most appropriate response?
- A. Let's discuss the different options and how you feel about them.'
- B. I can't help you to make a treatment decision about your treatment.'
- C. You need to discuss this decision with your physician.'
- D. I would choose surgery if I were in your position.'
Correct Answer: A
Rationale: Discussing options and feelings (A) supports the client's decision-making without giving direct advice. Other responses (B, C, D) dismiss the client's request or overstep the nurse's role.