Extract:

Nurses Notes
Client presents to the ED with substernal chest pain that comes and goes. The client states that the pain has been occurring for the last 8 hr. The pain, at times radiates down the left arm. Client also reports intermittent nausea
Client appears pale and slightly diaphoretic. Client rates current pain as 7 on a scale of 0 to 10

Question 1 of 5

Client presents to the ED with substernal chest pain that comes and goes. The client states that the pain has been occurring for the last 8 hr. The pain, at times radiates down the left arm. Client also reports intermittent nausea Client appears pale and slightly diaphoretic. Client rates current pain as 7 on a scale of 0 to 10. A nurse is caring for a client in the emergency department (ED). The nurse is planning care for the client. For each potential prescription. indicate whether it is indicated, nonessential, or contraindicated.

Options	Non- Anticipated	Essential	Contraindicated
Obtain intravenous (IV) access
Obtain the client's family history
Apply continuous ECG monitoring
Administer Oâ‚‚ to maintain oxygen saturation greater than 90%

Correct Answer: A,C,D

Rationale: Obtain intravenous (IV) access (
A), apply continuous ECG monitoring (
C), and administer Oâ‚‚ if saturation is below 90% (
D) are indicated for suspected MI. Obtaining family history (
B) is nonessential in the acute phase.

Extract:

Question 2 of 5

What is the underlying rationale for why a nurse assesses a client with emphysema for clinical indicators of hypoxia?

A. Increased mucus production blocks the alveoliB. Infections decrease ventilationC. Lack of adequate surface area for aerationD. Inflammation of the bronchioles decreases breathing capacity

Correct Answer: C

Rationale: Lack of adequate surface area for aeration is correct. Emphysema causes alveolar destruction, reducing gas exchange surface area, leading to chronic hypoxia. Mucus production, infections, and bronchiole inflammation are more relevant to chronic bronchitis or other conditions.

Question 3 of 5

A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make?

A. I recommend you exercise daily and avoid smoking to decrease your risk.B. Tell me more about these fears of dying from a heart attack.C. Of course you aren't going to die, at least not in the immediate future.D. Perhaps you should discuss this with your physician.

Correct Answer: B

Rationale: Encouraging the client to express fears allows emotional support and assessment. Providing health advice, dismissing fears, or referring to a physician too soon misses the opportunity for immediate support.

Question 4 of 5

A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a pulmonary embolism (PE)? (Select all that apply.)

A. Massage the calves every shift.B. Apply elastic compression stockings.C. Perform passive range of motion exercises.D. Assess legs for redness.E. Place pillows under the client's knees when in bed.

Correct Answer: B,C,D

Rationale: Applying elastic compression stockings (
B), performing passive range of motion exercises (
C), and assessing legs for redness (
D) are correct. These actions promote venous return, prevent stasis, and allow early detection of DVT, reducing PE risk. Massaging calves (
A) can dislodge clots, and pillows under knees (E) impair circulation, increasing clot risk.

Question 5 of 5

The client is being discharged with a prescription of prednisone. Which of the following is not a common side effect for this corticosteroid?

A. Weight lossB. Dry mouthC. HyperglycemiaD. Decreased wound healing

Correct Answer: A

Rationale: Weight loss is not a common side effect of prednisone. Weight gain due to fluid retention and increased appetite is typical. Dry mouth, hyperglycemia, and decreased wound healing are common side effects.