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Questions 163

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Question 1 of 5

The most common complication following a myocardial infarction is:

Correct Answer: B

Rationale: Cardiac dysrhythmias are the most common complication post-myocardial infarction due to ischemic changes affecting the heart's electrical conduction.

Question 2 of 5

The physician has ordered a sterile urine specimen to be collected from a client who has a Foley catheter. To obtain a sterile urine specimen, the nurse should:

Correct Answer: D

Rationale: Withdrawing from the catheter port with a syringe ensures a sterile specimen. Other methods risk contamination.

Question 3 of 5

The parent of a 7-month-old reports that the child has been crying and vomiting with a distended belly for the past 4 hours. The infant is now lying quietly in the parent's arms with a pulse of 200/min and respirations of 60/min. Which of the following components of SBAR (situation, background, assessment, recommendation/read back) communication is most important for the nurse to report?

Correct Answer: C

Rationale: The infant's lethargy with tachycardia (200/min) and tachypnea (60/min) are critical, suggesting a serious condition like intussusception or volvulus, requiring urgent reporting. Duration , perceived improvement , and laxative suggestion are less critical.

Question 4 of 5

A client who has a known history of cardiac problems and is still smoking enters the clinic complaining of sudden onset of sharp, stabbing pain that intensifies with a deep breath. The pain is occurring on only one side and can be isolated upon general assessment. The nurse concludes that this description is most likely caused by:

Correct Answer: A

Rationale: Pleurisy is an inflammation of the pleura and is often accompanied by abrupt onset of pain. Symptoms of pleurisy are abrupt pain that is usually unilateral and localized to a specific portion of the chest.

Question 5 of 5

The nurse prepares equipment for insertion of a large bore nasogastric (NG) tube for a hospitalized client. Which actions should the nurse take to measure and mark the tube? Select all that apply.

Correct Answer: C,D

Rationale:
To measure an NG tube, measure from nose to earlobe to xiphoid process for approximate insertion depth and mark with tape . Folding in half is inaccurate, measuring to stomach is vague, and rubber clamps are not standard.

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