Nokea
A 72 year-old client is scheduled to have a cardioversion. A nurse reviews the client's medication administration record. The nurse should notify the health care provider if the client received which medication during the preceding 24 hours?
- A. Digoxin (Lanoxin)
- B. Diltiazem (Cardizem)
- C. Nitroglycerine ointment
- D. Metoprolol (Toprol XL)
Correct Answer: A
Rationale: Digoxin (Lanoxin). Digoxin increases ventricular irritability and increases the risk of ventricular fibrillation following cardioversion. The other medications do not increase ventricular irritability.
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The nurse is assessing the client's abdomen. Which should the nurse do first?
- A. Auscultate
- B. Percuss
- C. Inspect
- D. Palpate
Correct Answer: C
Rationale: Abdominal assessment begins with inspection to observe for visible abnormalities, followed by auscultation, percussion, and palpation to avoid altering bowel sounds.
After the client returns to the unit, which of the following actions, if performed by the nurse, would be MOST appropriate?
- A. Position the client on her left side with her right arm protected in a sling.
- B. Position the client on her right side with her right arm elevated.
- C. Position the client in semi-Fowler's position with her right arm elevated.
- D. Position the client in the prone position with her right arm elevated.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) sling is not necessary, arm needs to be elevated (2) right arm cannot be elevated from this position (3) correct-this position will facilitate removal of fluid from venous pathways and lymphatic system through gravity; arm is elevated to enhance circulation and prevent edema (4) prone position is not appropriate
The nurse should anticipate the client with a gastric ulcer to have pain
- A. two to three hours after a meal.
- B. at night.
- C. relieved by ingestion of food.
- D. one-half to one hour after a meal.
Correct Answer: D
Rationale: pain related to a gastric ulcer occurs about one-half to one hour after a meal and rarely at night; is not helped by ingestion of food
A woman who recently had a simple mastectomy is about to be discharged. She seems very concerned about such things as where to find the best prosthesis, suitable underwear, and swimsuits, and adjusting to life with only one breast. Which resource is appropriate for the nurse to recommend?
- A. A psychologist or psychiatrist
- B. Reach to Recovery
- C. Pastoral counseling
- D. Her physician
Correct Answer: B
Rationale: Reach to Recovery offers peer support and resources for mastectomy patients, addressing prosthesis and lifestyle adjustments. Other options are less specific.
The nurse checks the incision of a patient 48 hours after surgery for a hernia repair. Which of the following findings would indicate a possible complication?
- A. There is swelling under the sutures.
- B. There is crusting around the incision line.
- C. The incision line is red.
- D. The incision line is approximated.
Correct Answer: C
Rationale: Strategy: Determine the significance of each answer choice. (1) slight swelling is expected during healing (2) slight crusting of incision line is normal (3) correct-should be pink, not red, indicates possible infection, other signs include increased warmth, tenderness, pain, and purulent or odorous drainage (4) shows healing is taking place