Nokea
The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?
- A. Diminished bowel sounds
- B. Loss of appetite
- C. A cold, pale lower leg
- D. Tachypnea
Correct Answer: C
Rationale: A cold, pale lower leg. This assessment suggests the presence of an embolus probably from the atrial fibrillation. Peripheral pulses should be checked immediately.
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A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin?
- A. Protamine
- B. Amicar
- C. Imferon
- D. Diltiazem
Correct Answer: A
Rationale: Protamine. Protamine binds heparin, making it ineffective.
A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?
- A. The tube will drain fluid from your chest.'
- B. The tube will remove excess air from your chest.'
- C. The tube controls the amount of air that enters your chest.'
- D. The tube will seal the hole in your lung.'
Correct Answer: B
Rationale: The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
The nurse is caring for the client with an IV. Which findings should prompt the nurse to conclude that the client is experiencing inflammation (phlebitis) at the IV insertion site? Select all that apply.
- A. Pain
- B. Redness
- C. Warmth
- D. Drainage
- E. Mottling
- F. Swelling
Correct Answer: A,B,C,F
Rationale: A: Pain indicates tissue irritation. B: Redness results from vasodilation. C: Warmth is caused by inflammation. F: Swelling occurs from fluid leakage. D: Drainage suggests infection. E: Mottling is unrelated.
The nursing student approaches the instructor after being stuck by a bloody needle. Which instructor statement is most accurate knowing that the client was HIV-positive?
- A. "Wash with soap and water and see the HCP now; treatment should begin within 1 to 2 hours."
- B. "The first HIV antibody testing is completed in 6 weeks and then repeated in 3 months."
- C. "Wash with soap and water now. At the end of the clinical shift, notify your physician."
- D. "Flush immediately with water for 10 minutes and then cover with a bandage and glove."
Correct Answer: A
Rationale: A: Immediate washing and HCP evaluation within 1-2 hours are critical for post-exposure prophylaxis. B: Testing timing is incorrect. C: Delaying care is risky. D: Flushing is for mucosal exposure.
The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to
- A. exercise doing weight bearing activities
- B. exercise to reduce weight
- C. avoid exercise activities that increase the risk of fracture
- D. exercise to strengthen muscles and thereby protect bones
Correct Answer: A
Rationale: exercise doing weight bearing activities. Weight bearing exercises are beneficial in the treatment of osteoporosis. Although loss of bone cannot be substantially reversed, further loss can be greatly reduced if the client includes weight bearing exercises along with estrogen replacement and calcium supplements in their treatment protocol.