Nokea
The nurse is administering lidocaine (Xylocaine) to a client with a myocardial infarction. Which of the following assessment findings requires the nurse's immediate action?
- A. Central venous pressure reading of 11
- B. Respiratory rate of 22
- C. Pulse rate of 48 BPM
- D. Blood pressure of 144/92
Correct Answer: C
Rationale: One of the side effects of lidocaine is bradycardia, heart block, cardiovascular collapse and cardiac arrest (this drug should never be administered without continuous EKG monitoring).
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A client with a total knee replacement returns from surgery. Which finding requires immediate nursing intervention?
- A. There is $30 \mathrm{~mL}$ of bloody drainage from the Davol drain.
- B. The continuous passive motion machine is set on $90^{\circ}$ flexion.
- C. The client is unable to ambulate to the bathroom.
- D. The client is complaining of muscle spasms.
Correct Answer: B
Rationale: A 90° flexion setting on the CPM machine is too aggressive post-surgery, risking injury, and requires immediate adjustment. Drainage , non-ambulation , and spasms are expected or less urgent.
A school-aged child informs the school nurse that his right knee 'doesn't feel right.' Which of the following actions should the nurse take FIRST?
- A. Instruct the child to extend the right leg.
- B. Put both of the child's legs through range-of-motion.
- C. Advise the child to soak the right knee in warm water.
- D. Compare the appearance of the right knee with the left knee.
Correct Answer: D
Rationale: Comparing knees assesses for swelling or deformity, the first step in physical assessment. Options A, B, and C risk exacerbating injury or are interventions before assessment.
The care of which of the following clients can the nurse safely delegate to an unlicensed assistive personnel (UAP)?
- A. A client with peripheral vascular disease and an ulceration of the lower leg.
- B. A pre-operative client awaiting adrenalectomy with a history of asthma
- C. An elderly client with hypertension and self-reported non-compliance
- D. A new admission with a history of transient ischemic attacks and dizziness
Correct Answer: A
Rationale: This client is stable with no risk of instability as compared to the other clients. The client has a chronic condition and needs supportive care, which is appropriate for a UAP.
Which of the following actions if taken by the nurse is BEST?
- A. Give the digoxin.
- B. Hold the digoxin.
- C. Notify the physician.
- D. Re-check the pulse.
Correct Answer: C
Rationale: Strategy: The topic of the question is unstated. (1) although the pulse is normal, level of potassium must be considered (2) notify physician about low potassium (3) correct-hypokalemia can precipitate digoxin toxicity; physician should be called to obtain order for potassium supplement (4) notify physician about the potassium level
A baby boy is delivered after a rapid labor of three hours. What nursing action takes priority in the immediate newborn period?
- A. Suctioning with a bulb syringe
- B. Wrapping the baby in warm blankets
- C. Applying identification bracelets and taking footprints
- D. Assigning an APGAR score
Correct Answer: A
Rationale: Suctioning with a bulb syringe clears airways, ensuring respiratory patency, the priority in the immediate newborn period to prevent aspiration.