Prometric Nursing DHA 001

A. Pulmonary embolism is correct because the sudden onset of chest pain and shortness of breath, along with tachycardia, are classic signs of this condition, which occurs when a blood clot blocks a pulmonary artery. B. Myocardial infarction could also cause chest pain and shortness of breath, but it typically presents with additional symptoms such as sweating or nausea and is often more gradual in onset. C. Pneumothorax can cause sudden chest pain and dyspnea, but it usually presents with decreased breath sounds on the affected side, which is not mentioned here. D. Gastroesophageal reflux disease can cause chest pain but is often associated with heartburn and regurgitation, making it less likely in this acute scenario.

Explanation: C. Administer bronchodilators is correct because bronchodilators, such as albuterol, provide rapid relief of bronchospasm during an asthma attack. A. Administer corticosteroids may be part of the management but is not the immediate intervention for acute symptoms as it takes longer to have an effect. B. Place the patient in a high Fowler’s position can help with breathing, but it is not the most critical intervention in an acute asthma attack. D. Obtain arterial blood gases is important for monitoring but is not a direct intervention to relieve the patient's symptoms.

Explanation: A. Weight gain of 2 lbs in 24 hours is correct because it can indicate fluid retention, which is a sign of worsening heart failure and requires immediate assessment and intervention. B. Increased urine output may indicate improved renal function and is generally a positive sign in a patient with heart failure. C. Decreased peripheral edema suggests that the patient's condition may be improving. D. Heart rate of 78 beats per minute is within normal limits and is not concerning in this context.

Explanation: C. Stiff neck is correct because it is a classic sign of meningitis, often accompanied by other symptoms such as fever and headache. A. Fever and chills can occur in many infections and are not specific to meningitis. B. Nausea and vomiting can occur in a variety of conditions, including migraines or gastrointestinal infections, and are not unique to meningitis. D. Cough and sore throat are more indicative of respiratory infections, not meningitis.

Explanation: B. Diabetic ketoacidosis is correct because a blood glucose level of 350 mg/dL in a patient with diabetes, particularly if they are type 1, raises concerns for DKA, which can cause metabolic acidosis. A. Hypoglycemia is unlikely given the high glucose level. C. Hyperglycemic hyperosmolar state is possible but is more commonly associated with significantly higher blood glucose levels and typically occurs in type 2 diabetes. D. Normal glucose metabolism is incorrect as the blood glucose level is well above normal.

Explanation: D. Monitor for signs of infection at the incision site is correct because patients need to be aware of infection signs (redness, swelling, drainage) post-surgery. A. Avoid all physical activity for two weeks is too restrictive; patients are usually encouraged to gradually increase activity. B. Take pain medication only if pain is severe is misleading; patients should take medications as prescribed to manage pain effectively. C. Resume a normal diet immediately may not be appropriate; patients are often advised to start with clear liquids and gradually progress.

Explanation: C. Elevated alanine aminotransferase (ALT) is correct as ALT is a liver enzyme; high levels indicate liver cell injury or dysfunction. A. Elevated serum glucose may suggest diabetes or stress but is not specific for liver dysfunction. B. Increased creatinine level indicates kidney dysfunction, not liver dysfunction. D. Decreased white blood cell count may indicate bone marrow issues or viral infections, not necessarily liver dysfunction.

Explanation: B. Clear the area of hazardous objects is correct as the immediate priority is to ensure the patient's safety during the seizure. A. Place a padded tongue blade in the patient's mouth is incorrect and dangerous; it can cause dental or oral injury and does not prevent aspiration. C. Administer oxygen via nasal cannula may be necessary but is not the immediate action during a seizure. D. Monitor the duration of the seizure is important, but ensuring the patient's safety is the priority.

Explanation: B. Increased respiratory rate is correct as it indicates the body is attempting to compensate for reduced oxygenation, a common finding in pneumonia. A. Decreased breath sounds can occur but are not specific and can be found in other conditions. C. Elevated blood pressure is not a typical finding in pneumonia; patients may be hypotensive in severe cases. D. Bradycardia is generally not associated with pneumonia and can indicate other issues.

Explanation: A. Monitor the patient’s temperature daily is correct because early detection of fever is crucial in patients with neutropenia to identify potential infections. B. Administer high-fiber foods is not recommended as a low-bacteria diet may be more appropriate to reduce infection risk. C. Encourage outdoor activities could expose the patient to infections; minimizing exposure is vital. D. Discontinue all medications is not appropriate without medical direction; patients should continue necessary medications unless advised otherwise.