A client with a history of myocardial infarction (MI) is receiving a beta-blocker medication. What is the most important outcome for the nurse to monitor?

Correct Answer: A

Rationale: The correct answer is A: Heart rate and blood pressure. When a client with a history of myocardial infarction (MI) is on a beta-blocker medication, monitoring heart rate and blood pressure is crucial. Beta-blockers lower heart rate and blood pressure, so monitoring these parameters helps assess the medication's effectiveness and prevent complications like bradycardia or hypotension. Choices B, C, and D are not the most important outcomes to monitor in this scenario. Blood glucose levels are typically monitored in clients with diabetes or when using medications that affect glucose levels. Respiratory rate is important in assessing respiratory function and oxygenation, while liver function tests are more relevant when monitoring the impact of medications on liver health.

Correct Answer: D

Rationale: To determine the amount of the 10% acetylcysteine solution to administer, convert the 1.4 grams to milligrams (1.4 grams = 1400 mg). Then, as the 10% solution contains 10 grams (10,000 mg) per 100 ml, it means there are 1000 mg of acetylcysteine in every 10 ml of the solution (10,000 mg / 100 ml = 100 mg/ml). Therefore, to administer 1400 mg (1.4 grams) of acetylcysteine, the nurse should give 14 ml of the 10% solution. Choices A, B, and C are incorrect as they do not accurately convert the amount of acetylcysteine to the corresponding volume of the 10% solution.

Correct Answer: B

Rationale: The correct answer is B: 'The technique is intended to maintain straight spinal alignment.' Log-rolling is a technique used to move a person as a single unit to maintain the alignment of the spinal column. This is crucial to prevent spinal cord injury, especially in clients with suspected spine fractures. Choice A is incorrect because log-rolling focuses on spinal alignment, not just decreasing back injury risks. Choice C is incorrect because the number of people involved is not the primary purpose of log-rolling, which is maintaining spinal alignment. Choice D is incorrect because while turning instead of pulling may help prevent skin damage, the primary goal of log-rolling is to protect the spine, not the skin.

Correct Answer: A

Rationale: During the preicteric phase of hepatitis A, the nurse should expect to find RUQ (right upper quadrant) abdominal pain. This pain is common in the early phase of hepatitis A and is associated with liver inflammation. Clay-colored stools (Choice B) are typically seen in the icteric phase when there is a lack of bile flow. Icteric sclera (Choice C) refers to yellowing of the eyes, which is a characteristic of the icteric phase. Pruritus (Choice D), which is itching of the skin, is also more commonly associated with the icteric phase when bile salts accumulate in the skin.

Correct Answer: D

Rationale: Shakiness is a known side effect of albuterol, which can often be managed without the need for additional medications. Educating the client about the potential side effects of albuterol, including shakiness, helps them understand what to expect and how to manage these effects. Administering an anxiolytic (Choice A) is not indicated as shakiness related to albuterol is not a sign of anxiety. Obtaining a 12-lead electrocardiogram (Choice B) is not necessary based on the client's presentation of shakiness and vital signs. Stopping the albuterol administration and restarting in 30 minutes (Choice C) may not be necessary since shakiness is a common side effect that can often be managed without interrupting the treatment.

Correct Answer: D

Rationale: The correct answer is D: Observation for and prevention of infection. Postoperative nursing care for a client with colon trauma primarily focuses on preventing infections. Clients with colon trauma are at high risk for infections due to the disruption of the intestinal barrier. Monitoring for signs of infection, maintaining proper wound care, administering antibiotics as prescribed, and implementing strict aseptic techniques are essential in preventing postoperative infections. Choices A, B, and C are incorrect because elevated coagulation studies, fistulas, and hyponatremia are not the primary concerns in the immediate postoperative period for a client with colon trauma.

Correct Answer: A

Rationale: The correct answer is option A because this client is the most stable and requires less supervision. Assigning a client whose discharge has been delayed due to a postoperative infection to the newly graduate practical nurse would be appropriate during a busy day as they are likely to need routine care and monitoring rather than immediate intensive interventions. Option B involves a client with poorly controlled type 2 diabetes on a sliding scale for insulin administration, which requires close monitoring and prompt intervention, making it a less suitable assignment for a new graduate who may need more guidance. Option C, a newly admitted patient with a head injury requiring frequent assessments, would demand a higher level of vigilance and expertise, which may be challenging for a new graduate nurse to handle without adequate supervision. Option D, a patient receiving IV heparin regulated based on protocol, involves complex medication management that may be too advanced for a new graduate nurse without sufficient oversight.

Correct Answer: C

Rationale: Following a thyroidectomy, tetany can occur due to hypoparathyroidism, leading to low calcium levels. Therefore, the nurse should administer calcium gluconate intravenously to raise the calcium levels. Choice A, Sodium iodide solution, is incorrect as it is used for thyroid conditions, not for treating tetany. Choice B, Levothyroxine sodium (Synthroid), is incorrect as it is a thyroid hormone replacement and does not address low calcium levels. Choice D, Propranolol (Inderal), is incorrect as it is a beta-blocker used for conditions like hypertension and not indicated for tetany after thyroidectomy.

Correct Answer: D

Rationale: Exploring the client's reasons for wanting to be discharged should be the first intervention as it helps to address underlying anxieties and concerns. By understanding the client's motivations, the nurse can provide appropriate support and interventions. It can also reduce distress and improve the therapeutic relationship. Reviewing the treatment plan (Choice A) may be important but addressing the immediate distress takes precedence. Informing the healthcare provider (Choice B) can be considered later if necessary. Determining if the client has PRN medication (Choice C) is relevant, but exploring the underlying reasons for the desire to be discharged is more beneficial in this situation.