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A client's telemetry monitor indicates the sudden onset of ventricular fibrillation. Which assessment finding should the nurse anticipate?
- A. Bounding erratic pulse.
- B. Regularly irregular pulse.
- C. Thready irregular pulse.
- D. No palpable pulse.
Correct Answer: D
Rationale: The correct answer is D: No palpable pulse. Ventricular fibrillation is a life-threatening arrhythmia where the heart quivers and doesn't effectively pump blood. This results in the absence of a palpable pulse. The nurse should anticipate this finding as it indicates a severe cardiac emergency requiring immediate intervention. Choices A, B, and C are incorrect because ventricular fibrillation leads to ineffective heart contractions, causing a lack of pulse rather than bounding, irregular, or thready pulses. It is crucial for the nurse to recognize the absence of a palpable pulse to initiate prompt resuscitative measures.
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When should surgical correction of hypospadias typically occur for a newborn infant as advised by the nurse?
- A. Repair should be done within one month to prevent bladder infections.
- B. Repairs should typically be done before the child is potty-trained.
- C. Delaying the repair until school age reduces castration fears.
- D. To form a proper urethra repair, it should be done after sexual maturity.
Correct Answer: B
Rationale: The correct answer is B because surgical correction of hypospadias is typically recommended before the child is potty-trained. This is important for optimal cosmetic and functional outcomes, as the procedure is more straightforward in infants due to their smaller anatomy. Delaying the surgery can lead to increased risk of complications and potential psychological impact on the child as they grow older.
A: Repair within one month to prevent bladder infections is not the primary reason for early correction of hypospadias.
C: Delaying the repair to school age for reducing castration fears is not a valid reason for postponing the surgery.
D: Waiting until after sexual maturity to form a proper urethra repair is not recommended as early correction typically yields better results.
After performing a paracentesis on a client with ascites, 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure?
- A. Pedal pulses.
- B. Breath sounds.
- C. Gag reflex.
- D. Vital signs.
Correct Answer: D
Rationale: The correct answer is D: Vital signs. After paracentesis, monitoring vital signs is crucial as fluid removal can lead to changes in blood pressure, heart rate, and overall fluid balance. Hypotension or tachycardia may indicate hypovolemia or shock. Pedal pulses (A) are important but not as critical post-paracentesis. Breath sounds (B) are important for respiratory assessment but not directly related to fluid removal. Gag reflex (C) is unrelated to paracentesis and not a priority post-procedure.
A patient with chronic obstructive pulmonary disease (COPD) is prescribed ipratropium. What is the primary action of this medication?
- A. Reduce inflammation
- B. Relieve bronchospasm
- C. Suppress cough
- D. Thin respiratory secretions
Correct Answer: B
Rationale: The correct answer is B: Relieve bronchospasm. Ipratropium is an anticholinergic bronchodilator that works by relaxing the muscles in the airways, leading to bronchodilation and improved airflow. This helps to relieve bronchospasm, a common symptom in COPD. Choice A is incorrect because ipratropium does not have significant anti-inflammatory effects. Choice C is incorrect as ipratropium does not directly suppress cough. Choice D is incorrect as ipratropium does not specifically target respiratory secretions.
A patient with chronic kidney disease (CKD) is prescribed erythropoietin. What is the primary action of this medication?
- A. Stimulate white blood cell production
- B. Increase platelet count
- C. Promote red blood cell production
- D. Enhance clotting factor production
Correct Answer: C
Rationale: The correct answer is C: Promote red blood cell production. Erythropoietin is a hormone that stimulates the production of red blood cells in the bone marrow. This is crucial for patients with CKD who often develop anemia due to decreased erythropoietin production.
A: Stimulating white blood cell production is the function of other medications, such as colony-stimulating factors, not erythropoietin.
B: Erythropoietin does not have an effect on platelet count.
D: Enhancing clotting factor production is not the primary action of erythropoietin.
A patient with an anxiety disorder is prescribed alprazolam. What is the primary action of this medication?
- A. Increase energy levels
- B. Induce sedation
- C. Elevate mood
- D. Reduce anxiety
Correct Answer: D
Rationale: The correct answer is D: Reduce anxiety. Alprazolam is a benzodiazepine that acts on the central nervous system to enhance the effects of a neurotransmitter called GABA, which helps to calm the brain and reduce anxiety. This medication does not increase energy levels (choice A), induce sedation (choice B), or elevate mood (choice C). Alprazolam's primary action is to target and alleviate the symptoms of anxiety by promoting relaxation and reducing excessive brain activity associated with anxiety disorders.