Exam (elaborations)

ATI NCLEX | QUESTIONS & ANSWERS/ RATIONALES, LATEST | NUR 101 | NCSBN TEST BANK - For The NCLEX-RN & NCLEX-PN

NUR 101 NCLEX Week 2 NCLEX QUIZ LATEST UPDATE 2020 1. The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a new systolic murmur at the apex. The nurse should first: A. Assess for changes in vital signs. B. Draw an arterial blood gas. C. Evaluate heart sounds with the client leaning forward. D. Obtain a 12 Lead electrocardiogram. Answer: A Rationale: Vital sign changes will reflect the severity of the sudden drop in cardiac output: decrease in blood pressure, increase in heart rate, and increase in respirations. ABG, heart sounds, are not the ways to detect severity of a murmur. A 12 lead electrogram would work in the case of an MI but not for the murmur. 2. A client with acute chest pain is receiving I.V. morphine sulfate. Which of the following results are intended effects of morphine in this client? Select all that apply. A. Reduces myocardial oxygen consumption. B. Promotes reduction in respiratory rate. C. Prevents ventricular remodeling. D. Reduces blood pressure and heart rate. E. Reduces anxiety and fear. Answer: A, D, E Rationale: Morphine sulfate acts as an analgesic and sedative. It reduces blood pressure, and heart rate by reducing the oxygen consumption of the myocardium. Morphine helps to reduces anxiety and fear. Its sedative effects help do this by slowing the heart rate. B, and C are not effects of morphine. 3. A client is receiving an IV infusion of heparin sodium at 1,200 units/h. The dilution is 25,000 units/500 mL. How many milliliters per hour will this client receive? Round your answer to a whole number. 24mL/H Rational: 25000/500=50 1200/50=24 4. An older client has chest pain and shortness of breath. The health care provider (HCP) prescribes nitroglycerin tablets. What should the nurse instruct the client to do? A. Put the tablet under the tongue until it is absorbed. B. Swallow the tablet with 120 mL of water. C. Chew the tablet until it is dissolved. D. Place the tablet between his cheek and gums. Answer: C