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Questions 158

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Extract:


Question 1 of 5

The nurse is caring for a client following a myocardial infarction. Which of the following enzymes are specific to cardiac damage?

Correct Answer: C

Rationale: CK-MB and LDH are specific to cardiac damage, with CK-MB being highly specific for myocardial infarction due to its presence in heart muscle.

Question 2 of 5

The nurse is caring for a client with a diagnosis of gestational hypertension. Which intervention is most appropriate?

Correct Answer: D

Rationale: Gestational hypertension requires blood pressure monitoring to assess severity antihypertensives for severe hypertension and fetal heart tone monitoring to ensure fetal well-being. All interventions are appropriate.

Question 3 of 5

The most important goal in the care plan for a child who was hospitalized with an accidental overdose would be to:

Correct Answer: D

Rationale: This goal is not the most important. There is always some guilt when an accident occurs; however, the priority is to be sure future accidents are prevented. Ipecac is not used for caustic alkali and acid ingestions. Determining the parent's knowledge about safety hazards and teaching appropriate preventive measures are likely to prevent recurrence of accidents.

Question 4 of 5

A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittent suction with orders to 'Irrigate NG tube with sterile saline q1h and prn.' The rationale for using sterile saline, as opposed to using sterile water to irrigate the NG tube is:

Correct Answer: A

Rationale: Water is a hypotonic solution and will deplete electrolytes and cause metabolic acidosis when used for nasogastric irrigation. Irrigating with saline does not cause abdominal discomfort. Severe, colicky abdominal pain is a symptom of intestinal obstruction. Irrigating with water will not cause restlessness or insomnia in the postoperative client. Restlessness and insomnia can be emotional complications of surgery. A nasogastric tube placed in the stomach is used to decompress the bowel. Irrigating with saline ensures a patent, well-functioning tube. Irrigating with saline will not increase peristalsis.

Question 5 of 5

A 72-year-old client with a new colostomy is being evaluated at the clinic today for constipation. When discussing diet with the client, the nurse recognizes that which one of the following foods most likely caused this problem?

Correct Answer: C

Rationale: Fried, greasy food, such as fried chicken, will produce diarrhealike stools in individuals with all types of GI ostomies. Eggs will cause odor-producing stools in individuals with all types of GI ostomies. Tapioca and rice products will cause constipation in individuals with all types of GI ostomies. Cabbage will cause odor-producing and flatus-producing stools in individuals with all types of GI ostomies.

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