A nurse is caring for a patient who has a history of myocardial infarction. The nurse should prioritize which of the following assessments?

Correct Answer: A

Rationale: The correct answer is A: Blood pressure and heart rate. This is crucial in assessing the cardiac function of a patient with a history of myocardial infarction. Monitoring blood pressure and heart rate helps in evaluating cardiovascular status and detecting any potential complications. Abnormal values in these parameters can indicate inadequate perfusion to the heart or other organs, which can be life-threatening. Other choices are incorrect because: B: Temperature and respiratory rate are important assessments but not the priority for a patient with a history of myocardial infarction. C: Bowel sounds and abdominal girth are more relevant for gastrointestinal issues and not a priority in this scenario. D: Urine output and skin integrity are important assessments for overall health but do not directly relate to the cardiovascular status in a patient with a history of myocardial infarction.

Correct Answer: C

Rationale: The correct answer is C, monitoring vital signs and fluid status, because it is crucial for assessing the patient's immediate post-operative condition and detecting any signs of complications like hemorrhage or shock. This step ensures early intervention if any issues arise, promoting patient safety and recovery. Administering pain medication (A) is important but not the top priority. Encouraging early ambulation (B) and providing wound care (D) are also essential but come after ensuring the patient's vital signs and fluid status are stable.

Correct Answer: B

Rationale: The correct answer is B: Providing a source of fast-acting carbohydrate. In a hypoglycemic episode, the priority is to raise the blood sugar quickly to prevent further complications. Fast-acting carbohydrates such as glucose tablets or orange juice can rapidly increase blood sugar levels. Administering insulin (choice A) can further lower blood sugar, checking blood glucose levels (choice C) may delay treatment, and contacting the healthcare provider (choice D) is not necessary in the immediate management of hypoglycemia.

Correct Answer: C

Rationale: The correct answer is C. This statement indicates a misunderstanding because stopping medication once blood pressure is normal can lead to a relapse of hypertension. Step 1: Medication management is crucial for long-term control of hypertension. Step 2: Stopping medication abruptly can cause blood pressure to rise again. Step 3: Regular monitoring, limiting sodium intake, and exercising are all important aspects of hypertension management. Summary: Choices A, B, and D demonstrate good understanding of hypertension management, while choice C shows a need for further education on the importance of continued medication use.

Correct Answer: A

Rationale: The correct answer is A: Quadriceps setting exercises. These exercises help prevent complications by strengthening the quadriceps muscles, which are crucial for knee stability and joint support post-surgery. They also aid in preventing muscle atrophy and promoting blood circulation. Leg lifts with weights (B) may strain the knee joint, leading to complications. Isometric muscle contractions (C) involve static muscle contractions and do not provide the necessary range of motion needed post-knee surgery. Active range-of-motion exercises (D) may be beneficial but should be performed after quadriceps setting exercises to avoid unnecessary strain on the knee joint.

Correct Answer: D

Rationale: The correct answer is D: Subjective data. During the interview portion of data collection, subjective data is obtained as it involves personal opinions, feelings, and experiences shared by the interviewee. This data is based on individual perspectives and cannot be measured objectively. Physical data (A) refers to tangible measurements, historical data (B) relates to past events or records, and objective data (C) is based on observable and measurable facts. In contrast, subjective data (D) captures the interviewee's viewpoints and interpretations, making it the most appropriate choice for the given scenario.

Correct Answer: B

Rationale: The correct answer is B: The diaphragm of the stethoscope. The diaphragm is used to assess heart murmurs as it allows for higher-frequency sounds to be heard more clearly. When assessing heart murmurs, using the diaphragm helps to differentiate between systolic and diastolic murmurs, as well as to identify specific characteristics such as intensity and location. A: The bell of the stethoscope is used for low-frequency sounds and would not be ideal for assessing heart murmurs. C: Palpation with the palm of the hand is used to assess pulses and vibrations, not heart murmurs. D: Asking another nurse to double-check the finding is important for validation but does not directly relate to the technique used to assess a heart murmur.

Correct Answer: B

Rationale: The correct answer is B: Assessment. The first step in the nursing process is to assess the patient's condition to gather data and information. In this case, assessing the patient's symptoms, vital signs, and history will help the nurse identify signs of pneumonia and determine the appropriate interventions. Diagnosis (A) comes after assessment, as it involves analyzing the data collected. Implementation (C) and Evaluation (D) are subsequent steps in the nursing process after assessment and diagnosis have been completed. Assessment is crucial for developing an effective care plan and ensuring the best possible outcomes for the patient.

Correct Answer: C

Rationale: The correct answer is C: Patient's level of consciousness. Assessing the patient's level of consciousness is crucial in a neurological assessment as it provides immediate information on the overall function of the brain. Changes in consciousness can indicate serious neurological issues such as head injuries or stroke. It is essential to prioritize assessing consciousness first to determine the urgency of the situation. Assessing reflexes (A), cranial nerve function (B), and pupil response (D) are also important in a neurological assessment but come after assessing the patient's level of consciousness, as they provide more specific and detailed information about the neurological status.