Question

A patient arrives at the clinic reporting a new onset of angina pectoris that has persisted for the last 30 minutes. What should be the nurse's initial action?

Answer 1

Correct Answers:

Obtain an EKG reading.

Rationale :

✍️ A client with new-onset angina lasting 30 minutes is at high risk for acute coronary syndrome or myocardial infarction (MI).

✍️ An electrocardiogram (EKG) should be the nurse’s first action to detect ischemic changes, such as ST-elevation or T-wave inversion.

✍️ Early identification of changes allows for timely interventions like oxygen, nitrates, and potential cardiac catheterization.

✍️ Time is critical — “time is muscle” in the context of cardiac ischemia.

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Answer 2

Correct Answers:

The ventricles contract

Rationale :

◈ During systole, the ventricles contract to eject blood into the aorta and pulmonary artery.

◈ This contraction produces the systolic blood pressure measured during a BP reading.

◈ It follows atrial contraction and is essential to effective systemic circulation.

◈ Systole ends when the ventricles relax, marking the beginning of diastole.

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Answer 3

Correct Answers:

Elevate the head of the patient's bed to an upright position.

Rationale :

▪ In a patient with COPD and a pulse oximetry reading of 89%, the priority is to enhance oxygen exchange.

▪ Elevating the head of the bed maximizes lung expansion and helps reduce the work of breathing.

▪ This non-invasive intervention is safe, immediate, and often effective in improving oxygen saturation.

▪ Further interventions like oxygen therapy can follow after positioning and assessment

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Answer 4

Correct Answers:

Misdemeanor

Rationale :

🔷 Parking violations, such as parking on a sidewalk, are classified as misdemeanors, not felonies.

🔷 Misdemeanors are less severe criminal offenses that typically result in fines or short-term imprisonment.

🔷 These offenses are handled within the criminal law system, although they are considered non-violent infractions.

🔷 They are often governed by municipal codes or traffic regulations.

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Answer 5

Correct Answers:

Home health care.

Rationale :

👉 Home health care is a tertiary care service focused on helping patients recover and regain function after acute hospitalization.

👉 It commonly includes physical therapy, medication monitoring, and wound care in the home setting.

👉 In this scenario, it helps the patient regain mobility and independence after a hip fracture.

👉 This intervention supports rehabilitation goals and reduces the risk of hospital readmission.

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Answer 6

Correct Answers:

"I'm concerned about how you expressed your concern in front of the other staff members and the patient. It made me feel uncomfortable in front of them."

Rationale :

✳️ The "E" in DESC stands for "Express your emotions or feelings" in a respectful, clear manner.

✳️ This step promotes assertive communication without defensiveness or blame.

✳️ It helps the nurse address the issue of public criticism, which can affect both morale and patient trust.

✳️ Expressing feelings encourages a collaborative resolution and reinforces professionalism.

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Answer 7

Correct Answers:

The nurse should cross out the error with a single line so the original documentation can be seen and sign and date the correction.

Rationale :

▧ According to CMS guidelines, errors in paper documentation should be corrected using a single line so the original entry remains visible.

▧ The nurse should then initial and date the correction, without using white-out or erasing.

▧ This practice ensures legal integrity and transparency of the medical record.

▧ It allows for accurate tracking of changes and protects the document from claims of falsification.

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Answer 8

Correct Answers:

Social Support.

Rationale :

✔️ Allowing frequent family visits addresses the patient’s need for emotional and social support, which is essential for holistic care.

✔️ Family presence provides comfort, reassurance, and a sense of normalcy, especially in ICU settings.

✔️ Social support has been shown to improve coping, adherence, and even health outcomes.

✔️ This reflects an understanding of psychosocial needs in critical care.

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Answer 9

Correct Answers:

Her pain is rated 10/10 on a numerical scale.

Rationale :

▲ In SBAR communication, “A” stands for Assessment, which involves objective or subjective findings relevant to the patient’s condition.

▲ A pain score of 10/10 provides quantifiable evidence that supports the need for further intervention.

▲ Including assessment data strengthens the case when communicating with providers.

▲ It helps the receiver prioritize care and make decisions based on clinical urgency.

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Answer 10

Correct Answers:

A red wound with exudate is an example of objective data.

Rationale :

➡️ Objective data are measurable, observable findings such as vital signs, lab values, or physical characteristics.

➡️ Descriptions like “red wound with exudate” fall under this category because they are verifiable and seen by the nurse.

➡️ This contrasts with subjective data, which includes the patient’s feelings or descriptions.

➡️ Correct documentation must distinguish between what is observed and what is reported.

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RN Medsurg Nur2141

No.

1 :
A patient arrives at the clinic reporting a new onset of angina pectoris that has persisted for the last 30 minutes. What should be the nurse's initial action?

2 :
What events take place during systole?

3 :
A patient with chronic obstructive pulmonary disease (COPD) is experiencing shortness of breath while breathing room air. The patient's pulse oximetry reading is 89% and their respiratory rate is 22. What should be the nurse's priority action?

4 :
A person receives a ticket for parking their car on a sidewalk. How would this offense be classified in terms of criminal law?

5 :
A patient has been discharged home following a hospital stay for a hip fracture sustained in a fall. The provider has ordered physical therapy to help the patient regain strength and flexibility. To which tertiary service is the patient likely to be referred?

7 :
A nurse working in a care area that uses paper charting notices an error when recording a patient's vital signs in the patient record. Which option adheres to The Centers for Medicare & Medicaid Services (CMS) guidelines for making corrections to documentation?

8 :
An ICU nurse has had many discussions with fellow nursing colleagues about allowing patient families to visit as often as the patient's condition will allow. Which patient and family need is the nurse considering in these conversations?

9 :
In the context of SBAR Communication, which part of the following message corresponds to the "A" in SBAR?

10 :
Which statement accurately describes the relationship between subjective and objective data in documentation?

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RN Medsurg Nur2141

No.

1 : A patient arrives at the clinic reporting a new onset of angina pectoris that has persisted for the last 30 minutes. What should be the nurse's initial action?

2 : What events take place during systole?

3 : A patient with chronic obstructive pulmonary disease (COPD) is experiencing shortness of breath while breathing room air. The patient's pulse oximetry reading is 89% and their respiratory rate is 22. What should be the nurse's priority action?

4 : A person receives a ticket for parking their car on a sidewalk. How would this offense be classified in terms of criminal law?

5 : A patient has been discharged home following a hospital stay for a hip fracture sustained in a fall. The provider has ordered physical therapy to help the patient regain strength and flexibility. To which tertiary service is the patient likely to be referred?

7 : A nurse working in a care area that uses paper charting notices an error when recording a patient's vital signs in the patient record. Which option adheres to The Centers for Medicare & Medicaid Services (CMS) guidelines for making corrections to documentation?

8 : An ICU nurse has had many discussions with fellow nursing colleagues about allowing patient families to visit as often as the patient's condition will allow. Which patient and family need is the nurse considering in these conversations?

9 : In the context of SBAR Communication, which part of the following message corresponds to the "A" in SBAR?

10 : Which statement accurately describes the relationship between subjective and objective data in documentation?

1 :
A patient arrives at the clinic reporting a new onset of angina pectoris that has persisted for the last 30 minutes. What should be the nurse's initial action?

2 :
What events take place during systole?

3 :
A patient with chronic obstructive pulmonary disease (COPD) is experiencing shortness of breath while breathing room air. The patient's pulse oximetry reading is 89% and their respiratory rate is 22. What should be the nurse's priority action?

4 :
A person receives a ticket for parking their car on a sidewalk. How would this offense be classified in terms of criminal law?

5 :
A patient has been discharged home following a hospital stay for a hip fracture sustained in a fall. The provider has ordered physical therapy to help the patient regain strength and flexibility. To which tertiary service is the patient likely to be referred?

7 :
A nurse working in a care area that uses paper charting notices an error when recording a patient's vital signs in the patient record. Which option adheres to The Centers for Medicare & Medicaid Services (CMS) guidelines for making corrections to documentation?

8 :
An ICU nurse has had many discussions with fellow nursing colleagues about allowing patient families to visit as often as the patient's condition will allow. Which patient and family need is the nurse considering in these conversations?

9 :
In the context of SBAR Communication, which part of the following message corresponds to the "A" in SBAR?

10 :
Which statement accurately describes the relationship between subjective and objective data in documentation?