Nokea
The nurse has just received report from the previous shift.
Which of the following patients should the nurse see FIRST?
- A. A patient who had coronary artery bypass graft (CABG) and will have the atrioventricular (AV) wires removed later in the day.
- B. A patient with type I diabetes who is scheduled for a cardiac catheterization later today.
- C. A patient who is one-day postoperative and has an epidural catheter in place.
- D. A patient who is being evaluated for a heart transplant.
Correct Answer: C
Rationale: Strategy: Determine which patient is the least stable. (1) although the patient requires a high level of nursing care, no indication that the patient is unstable (2) patient requires preoperative assessment and teaching, no indication that the patient is unstable (3) correct-epidural used for pain relief, monitor for urinary incontinence, hypotension, respiratory depression, and nausea and vomiting (4) requires monitoring but patient with epidural takes priority
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A client arrives at the emergency room with an HR of 120, an RR of 48, and hemoptysis. The nurse should give priority to:
- A. Obtaining a history of the current illness
- B. Applying oxygen via mask
- C. Obtaining additional vital signs
- D. Checking arterial blood gases
Correct Answer: B
Rationale: Hemoptysis and tachypnea suggest respiratory distress, so oxygen administration is the priority to stabilize the client.
In order to be effective in administering cardiopulmonary resuscitation to a 5 year-old, the nurse must
- A. Assess the brachial pulses
- B. Breathe once every 5 compressions
- C. Use both hands to apply chest pressure
- D. Compress 80-90 times per minute
Correct Answer: B
Rationale: Breathe once every 5 compressions. For a 5 year-old, the nurse should give 1 breath for every 5 compressions.
Which of the following statements describes Piaget's stage of concrete operations?
- A. Reflex activity proceeds to imitative behavior.
- B. There is an increased ability to see another's point of view.
- C. Thought processes become more logical and coherent.
- D. The ability to think abstractly leads to logical conclusions.
Correct Answer: C
Rationale: Concrete operations (ages 7-11) involve logical, coherent thought about concrete events. Perspective-taking develops but is not primary, and abstract thinking is characteristic of later stages.
A client is seen in the emergency room with complaints of chest pain.
- A. Which assessment finding suggests to the nurse that the client’s chest pain is cardiac in origin?
- B. The client states that the pain is sharp and increased by deep breathing.
- C. The client reports a history of a fatty meal before the pain began.
- D. The client states that the pain is substernal and radiates to the left arm.
- E. The client reports that the pain began when he was lifting a heavy object.
Correct Answer: C
Rationale: Substernal chest pain radiating to the left arm is a classic symptom of cardiac ischemia, such as angina or myocardial infarction. Sharp pain with breathing suggests pleuritic causes, fatty meals indicate gastroinTest inal issues, and pain with lifting suggests musculoskeletal strain.
The nurse is caring for a client with a history of chronic lymphocytic leukemia.
- A. Which symptom should the nurse report immediately for a client with chronic lymphocytic leukemia?
- B. Fatigue and weakness.
- C. Enlarged, painless lymph nodes.
- D. Fever and night sweats.
- E. A hemoglobin of 9.0 g/dL.
Correct Answer: C
Rationale: Fever and night sweats may indicate infection or disease progression in chronic lymphocytic leukemia, requiring immediate evaluation. Fatigue, lymph node enlargement, and low hemoglobin are expected.