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Question 1 of 5

The nurse is caring for a client post-myocardial infarction on the cardiac unit. The client is exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?

Correct Answer: B

Rationale: Chest pain is a hallmark of cardiogenic shock due to myocardial ischemia, distinguishing it from anaphylactic shock, which typically involves urticaria or bronchospasm. Low BP (
A) and anxiety (
C) are common in both, and normal temperature (
D) is nonspecific.

Question 2 of 5

The nurse is teaching basic newborn care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first two weeks of life because:

Correct Answer: B

Rationale: Sponge baths are recommended until the umbilical cord separates (typically within 1-2 weeks) to keep the cord dry and prevent infection. The other reasons are not the primary rationale for this practice.

Question 3 of 5

The nurse is caring for a client after a motor vehicle accident. The client has a fractured tibia, and bone is noted protruding through the skin. Which action is of priority?

Correct Answer: B

Rationale: Covering an open fracture with a sterile dressing prevents infection, a priority. Traction (
A) is secondary, an ACE bandage (
C) may contaminate the wound, and prone positioning (
D) is inappropriate.

Question 4 of 5

The client with chronic obstructive pulmonary disease (COPD) is prescribed ipratropium (Atrovent). The nurse should teach the client to:

Correct Answer: B

Rationale: Ipratropium, an anticholinergic bronchodilator, can cause blurred vision, a side effect requiring immediate reporting. It is not taken with meals, is used every 6–8 hours, and water restriction is unnecessary.

Question 5 of 5

Which task should be delegated to the licensed practical nurse?

Question Image

Correct Answer: A, B, D, E

Rationale: LPNs can administer subcutaneous heparin (
A), feed via PEG tube (
B), monitor chest tubes (
D), and perform tracheostomy care (E). Removing a PICC line (
C) requires RN-level expertise due to potential complications.

Similar Questions

A 45-year-old male client experiences a sense of depression because he has not yet achieved his life's goals. His career has not been satisfying. He is still looking for the right job. His wife spends too much money, and his children seem to ignore him while being very selfish. He is tired of all of their attitudes and is considering buying a red Corvette convertible. While obtaining these data concerning the client's feelings about his life, the nurse is able to determine he is experiencing what psychological crisis according to Erikson's stages?
The client is diagnosed with a tension pneumothorax. Which intervention should the nurse anticipate?
A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, 'Why did this happen to my baby?' is:
The nurse is teaching a mother care of her child's spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be:
A client with multiple sclerosis has an order to receive Solu Medrol 200mg IV push. The available dose is Solu Medrol 250 mg per mL. How many mL should the nurse administer?

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