what is the primary action a nurse should take when a patient with a suspected myocardial infarction mi arrives in the emergency department
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Nursing Elites

HESI LPN

HESI PN Exit Exam

1. What is the primary action a healthcare professional should take when a patient with a suspected myocardial infarction (MI) arrives in the emergency department?

Correct answer: B

Rationale: Administering oxygen and obtaining an ECG are crucial initial steps when managing a suspected myocardial infarction (MI). Oxygen helps improve oxygenation to the heart muscle, while an ECG is essential to diagnose an MI promptly. Applying a cold compress, encouraging the patient to walk, or providing a high-carbohydrate meal are not appropriate actions in the initial management of a suspected MI. Applying a cold compress can delay necessary interventions, encouraging the patient to walk may worsen the condition, and providing a high-carbohydrate meal is irrelevant to the immediate needs of a patient with a suspected MI.

2. How does the home care nurse determine that a 78-year-old client is unable to remain in his current residence alone?

Correct answer: C

Rationale: The correct answer is assessing the home environment. This process is vital in evaluating whether an elderly client can safely live independently. Factors like safety hazards and the client's ability to handle daily activities are considered during this assessment. Choices A, B, and D are incorrect because determining the client's ability to remain in his residence alone relies more on evaluating the home environment for safety and suitability rather than the client's goals, learning level, or distractions in the home.

3. Which cranial nerve is responsible for the sense of smell?

Correct answer: A

Rationale: The olfactory nerve (Cranial Nerve I) is indeed responsible for the sense of smell. It is located in the nasal cavity and transmits olfactory information to the brain. The optic nerve (Choice B) is responsible for vision, the trigeminal nerve (Choice C) is responsible for sensation in the face, and the vagus nerve (Choice D) is responsible for various functions such as heart rate, digestion, and speech. Therefore, the correct answer is the olfactory nerve (Choice A).

4. The nurse is caring for an elderly female client who tells the nurse, 'When I sneeze, I wet my pants.' After discussing the client's complaint with the charge nurse, the nurse plans to reinforce teaching about the importance of Kegel exercises. What muscles are involved in these exercises?

Correct answer: D

Rationale: Kegel exercises involve the pelvic floor muscles. These muscles help strengthen the muscles controlling urination, potentially reducing symptoms of urinary incontinence. Pectoral muscles (Choice A), responsible for movement of the shoulders and arms, are not involved in Kegel exercises. Buttock muscles (Choice B) are primarily responsible for hip movement and stability, not related to Kegel exercises. Abdominal muscles (Choice C) support the core and trunk but are not the focus of Kegel exercises.

5. Prior to giving digoxin, the PN assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take?

Correct answer: B

Rationale: A heart rate of 120 beats per minute is within the normal range for a 2-month-old infant. Therefore, it is safe to administer the digoxin and document the heart rate as part of routine care. Choice A is incorrect as withholding the medication is not necessary since the heart rate is normal. Choice C is incorrect as there is no need to delay the administration until the next scheduled dose when the heart rate is within the normal range. Choice D is incorrect as the primary nurse is not needed to administer the medication since the heart rate is normal and falls within the safe range for administration.

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