a client presents to the emergency department with symptoms of a myocardial infarction what should the nurse administer immediately under doctors orde a client presents to the emergency department with symptoms of a myocardial infarction what should the nurse administer immediately under doctors orde
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Nursing Elites

HESI LPN

Adult Health 1 Final Exam

1. A client presents to the emergency department with symptoms of a myocardial infarction. What should the nurse administer immediately under doctor's orders?

Correct answer: A

Rationale: The correct answer is A: Aspirin to prevent further blood clotting. Administering aspirin is crucial in the immediate management of a myocardial infarction as it helps prevent further blood clot formation, which is a key component in the treatment and prevention of myocardial infarction. Oxygen therapy (Choice B) is often provided, but aspirin takes precedence due to its role in reducing clot formation. Intravenous fluids (Choice C) may be needed but are not the immediate priority in this situation. Nitroglycerin (Choice D) is commonly used for chest pain relief in myocardial infarction but is not the first medication to be administered in this scenario.

2. A client is being taught about medications at discharge. Which statement should the nurse identify as an indication that the client understands the instructions?

Correct answer: B

Rationale: The correct answer is B. Adding liquid medication to pudding can help with swallowing difficulties, demonstrating understanding of the instructions. Options A and C are incorrect as altering time-release capsules and enteric-coated pills is not recommended in medication administration. Option A is incorrect as time-release capsules should not be opened and sprinkled on food, affecting their efficacy. Option C is incorrect as crushing enteric-coated pills can affect their absorption. Option D is unrelated to medication administration and does not demonstrate understanding of the instructions.

3. What is a common early sign of RSV (respiratory syncytial virus) in infants?

Correct answer: B

Rationale: Nasal congestion is a common early sign of RSV in infants, often accompanied by cough and wheezing. High fever, rash, and jaundice are not typically associated with RSV. While RSV can lead to fever, it is usually not one of the earliest signs. Rash and jaundice are unrelated to RSV symptoms.

4. When a client with schizophrenia is being discharged on antipsychotic medication, what is the most important instruction the nurse should provide?

Correct answer: C

Rationale: The correct answer is to instruct the client to report any unusual muscle movements immediately. These movements may indicate extrapyramidal symptoms (EPS) or tardive dyskinesia, which are serious side effects of antipsychotic medications that require immediate attention. Choice A is incorrect because stopping the medication without medical advice can lead to a relapse of symptoms. Choice B is important but not as critical as monitoring for EPS. Choice D is incorrect because driving readiness is not directly related to antipsychotic medication instructions.

5. A client with diabetes mellitus presents with confusion and diaphoresis. What is the priority nursing action?

Correct answer: A

Rationale: The correct answer is to check the blood glucose level. In a client with diabetes mellitus presenting with confusion and diaphoresis, it is important to assess the blood glucose level first to determine if the symptoms are due to hypoglycemia. Administering insulin immediately (Choice B) without knowing the blood glucose level can worsen the condition if the client is hypoglycemic. Offering a high-protein snack (Choice C) is not appropriate as the severity of hypoglycemia is unknown, and placing the client in a supine position (Choice D) is not the priority action for these symptoms.

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