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Question 1 of 5

A client admitted with a diagnosis of possible myocardial infarction is admitted to the unit from the emergency room. The nurse's first action when admitting the client will be to:

Correct Answer: B

Rationale: Obtaining vital signs is important after connecting the client to the monitor because vital signs should be stable before the client is discharged from the emergency room. All are important, but the first priority is to monitor the client's rhythm. If the client is in severe pain, pain medication should be given after connecting him to the monitor and obtaining vital signs. Completion of the history profile is the least important of the nursing actions.

Question 2 of 5

A patient with a PCA pump (patient controlled analgesia) asks the nurse if he can become overdosed with pain medication using this machine. Which statement made by the nurse is correct?

Correct Answer: B

Rationale: PCA pumps have a lockout interval and dose limits programmed to prevent overdose, ensuring safe administration of pain medication. The other statements are inaccurate: PCA requires patient action, does not deliver large doses every four hours, and is not based on ‘need’ detection.

Question 3 of 5

The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse knows that RhoGam is given at:

Correct Answer: B

Rationale: RhoGam is administered intramuscularly, typically in the deltoid muscle, for Rh-negative mothers to prevent sensitization. The other locations are incorrect for IM injections of RhoGam.

Question 4 of 5

The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the:

Correct Answer: A

Rationale: The phlebostatic axis (located at the fourth intercostal space mid-axillary line) is the standard reference point for zeroing the manometer to accurately measure central venous pressure. The other options are incorrect anatomical landmarks.

Question 5 of 5

The charge nurse is assigning staff for the day. Staff consists of an RN, an LPN, and a certified nursing assistant. Which client assignment should be given to the nursing assistant?

Correct Answer: B

Rationale: A stable stroke client (hospitalized for two days) is appropriate for a nursing assistant, who can assist with basic care (e.g., hygiene, mobility). Recent surgery (
A), PCA morphine (
C), and new admissions (
D) require higher-level nursing skills.

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