In planning care for the patient with acute myocardial infarction (AMI), the nurse identifies the highest priority goal of care as which of the following?

Stable ECG rhythm

Ability to verbalize causes and eﬀects of CHD/CAD

Adequate relief of pain

Compliance with prescribed bedrest

Answer and Explanation

The Correct Answer is C

Choice A reason: While a stable ECG rhythm is important, it is not the immediate concern post-AMI.

Choice B reason: The ability to verbalize causes and eﬀects of CHD/CAD is an educational goal, not an immediate care priority.

Choice C reason: Adequate relief of pain is a priority to reduce stress on the heart and improve patient comfort.

Choice D reason: Compliance with prescribed bedrest is important but secondary to pain relief.

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Correct Answer is B

Explanation

Choice A reason: Showing the patient that her leg is gone does not address the immediate concern of pain management.

Choice B reason: Administering the prescribed pain medication is the first step in managing phantom pain, which is a common experience for amputees.

Choice C reason: While it is important to validate the patient's experience of pain, the first action should be to address the pain medically.

Choice D reason: Telling the patient that it is not possible to feel pain in her toes is incorrect and dismissive of the phenomenon of phantom pain.

A. The client has at least one stool per day. B. The client denies nausea and vomiting (N/V). C. The client's bilirubin level decreases. D. The client is alert and oriented (A&Ox4).

Correct Answer is D

Explanation

Choice A reason: While having at least one stool per day is a sign that lactulose is working, it does not directly indicate its eﬀectiveness in reducing ammonia levels and improving mental status.

Choice B reason: Denial of nausea and vomiting is positive but is not a direct indicator of lactulose's eﬀectiveness in treating hepatic encephalopathy.

Choice C reason: A decrease in bilirubin levels may be a positive sign, but it is not a direct indicator of lactulose's eﬀectiveness in treating hepatic encephalopathy.

Choice D reason: The client being alert and oriented is a direct indicator that lactulose is eﬀectively reducing ammonia levels and improving mental status, which is a key goal in treating hepatic encephalopathy associated with liver cirrhosis.

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In planning care for the patient with acute myocardial infarction (AMI), the nurse identifies the highest priority goal of care as which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client in the PACU with a left below-the-knee amputation complains of pain in her left big toe. Which of the following would the nurse do first?

Correct Answer is B

Explanation

Which of the following indicate to the nurse that lactulose is eﬀective for an older adult who has advanced liver cirrhosis?

Correct Answer is D

Explanation

The nurse evaluates her teaching as eﬀective when the patient recovering from acute renal failure states that he will do which of the following?

A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 11:30. The nurse should begin the infusion at which of the following times?

A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?

An adult male with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. Which laboratory data would the nurse identify as consistent with these symptoms?

Which action should the nurse take first when a patient is seen in the outpatient clinic with neck pain?

A recommended position for a patient in acute pulmonary edema is:

The normal PR interval is:

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?