Nokea
Which of the following lab values is elevated first after a client has a myocardial infarction?
- A. LDH
- B. troponin
- C. CPK
- D. SGOT
Correct Answer: B
Rationale: Troponin is the earliest and most specific marker to rise after a myocardial infarction, detectable within hours of cardiac injury.
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The nurse is preparing to administer IV Vancomycin to a client. Which of the following nursing actions should be taken first?
- A. performing a physical assessment prior to administration
- B. obtaining the most recent lab values regarding renal function
- C. reviewing peaks and troughs for the past few days
- D. ensuring the client is not allergic to the medication
Correct Answer: D
Rationale: Even before the physical assessment (which might or might not be indicated at the time of administration of Vancomycin), ensuring that the client is not allergic to the medication is the most critical action the nurse must take before administering any drug. Lab values regarding renal functioning and therapeutic ranges via peaks and troughs are also important with some medications such as Vancomycin because renal damage can occur if blood drug levels remain high over time.
All of the following should be performed when fetal heart monitoring indicates fetal distress except:
- A. increase maternal fluids.
- B. administer oxygen.
- C. decrease maternal fluids.
- D. turn the mother.
Correct Answer: C
Rationale: Decreasing maternal fluids is the only intervention that should not be performed when fetal distress is indicated.
A community health nurse is asked to organize a health promotion project that plans to provide glucose screening. This activity is most beneficial within what realm?
- A. Testing that is performed by volunteers at a local department store and is open to the public
- B. At a professional health fair activity available for selected persons who have been screened as being at risk
- C. Mass-marketing vouchers for free fingersticks at a local drug store, where the pharmacist makes recommendations on the findings
- D. Testing that is performed by a nurse professional, who immediately provides education regarding the findings
Correct Answer: B
Rationale: Glucose screening is most effective for high-risk or symptomatic individuals at a health fair, ensuring targeted and meaningful results.
How often must physical restraints be released?
- A. every 2 hours
- B. between 1 and 3 hours
- C. every 30 minutes
- D. at least every 4 hours
Correct Answer: A
Rationale: Restraints must be released every 2 hours to assess circulation, skin integrity, and client comfort, with assessments every 30 minutes while restrained.
When the nurse is determining the appropriate size of an oropharyngeal airway to insert, what part of a client's body should she measure?
- A. corner of the mouth to the tragus of the ear
- B. corner of the eye to the top of the ear
- C. tip of the chin to the sternum
- D. tip of the nose to the earlobe
Correct Answer: A
Rationale: An oropharyngeal airway is measured from the corner of the client's mouth, to the tragus of the ear.