a client with a history of hypertension is admitted to the hospital for a suspected myocardial infarction which of the following is the priority nursi
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Nursing Elites

HESI LPN

Adult Health Exam 1 Chamberlain

1. A client with a history of hypertension is admitted to the hospital for a suspected myocardial infarction. Which of the following is the priority nursing action?

Correct answer: B

Rationale: The priority nursing action in this scenario is to perform an ECG. An ECG is crucial in confirming myocardial infarction promptly and guiding immediate treatment decisions. Administering oxygen as prescribed is important but not the priority over confirming the diagnosis. Obtaining a detailed health history is relevant but does not take precedence over immediate diagnostic confirmation. While monitoring vital signs regularly is essential, performing an ECG is the priority action in this scenario to guide timely management.

2. The nurse is caring for a 75-year-old male client who is beginning to form a decubitus ulcer at the coccyx. Which intervention will be most helpful in preventing further development of the decubitus ulcer?

Correct answer: A

Rationale: Encouraging the client to eat foods high in protein is crucial in preventing further development of decubitus ulcers as high protein foods support tissue repair and skin integrity. Adequate protein intake is essential for wound healing. Assessing the client for daily range of motion exercises is important for preventing complications related to immobility, but it may not directly address the prevention of decubitus ulcers. Teaching the family how to perform sterile wound care is significant for wound management but may not be the most effective intervention to prevent further development of decubitus ulcers. Ensuring IV fluids are administered as prescribed is essential for maintaining hydration status but is not the most relevant intervention for preventing decubitus ulcers.

3. What is the function of the cervix in reproduction?

Correct answer: B

Rationale: The cervix functions in reproduction by secreting mucus that facilitates the transport of sperm to the uterus. Choice A is incorrect because the cervix does not interpret signals of sexual stimuli. Choice C is incorrect as the site for the union of ovum and sperm is the fallopian tube. Choice D is incorrect as the cervix is not involved in receiving the penis during intercourse.

4. Which intervention is most effective in preventing the spread of infection in a healthcare setting?

Correct answer: C

Rationale: Practicing hand hygiene is the most effective measure to prevent the spread of infection in healthcare settings. While wearing gloves, using hand sanitizer, and disinfecting surfaces are important infection control measures, they are not as effective as proper hand hygiene. Hand hygiene, including handwashing with soap and water or using alcohol-based hand sanitizers, is crucial in preventing the transmission of pathogens from one person to another, making it the best choice among the options provided. Wearing gloves primarily protects the wearer and is not a substitute for hand hygiene. Using hand sanitizer is helpful but may not be as effective as proper handwashing. Disinfecting surfaces is important but does not address the direct transmission of pathogens through hand contact, which hand hygiene effectively prevents.

5. What is the primary function of neutrophils?

Correct answer: C

Rationale: The correct answer is C: Phagocytotic action. Neutrophils are key components of the immune system, primarily involved in the phagocytosis of bacteria and other pathogens. Choice A, Heparin secretion, is incorrect as heparin is primarily secreted by mast cells and basophils. Choice B, Transport oxygen, is incorrect as this is mainly the function of red blood cells. Choice D, Antibody formation, is incorrect as antibody production is primarily carried out by B lymphocytes.

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