Nokea
A 6-year-old child has a systolic blood pressure between the 95th and 99th percentile for age, sex, and height and a diastolic blood pressure between the 90th and the 95th percentile on three separate clinic visits. This child's blood pressure is placed in which classification?
- A. normotensive
- B. pre-hypertensive
- C. stage 1 hypertensive
- D. stage 2 hypertensive
Correct Answer: C
Rationale: Stage 1 hypertensive pressure ranges from the 95th percentile or from 120/80 mm Hg to 5 mm Hg above the 99th percentile for age, sex, and height for either systolic or diastolic pressure.
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Sudden death in an athlete immediately after forceful blunt trauma to the chest is most likely
- A. commotio cordis
- B. myocardial infarction
- C. lacerated coronary artery
- D. ruptured cardiac tendineae
Correct Answer: A
Rationale: Commotio cordis occurs due to sudden arrhythmias triggered by chest trauma during a vulnerable phase of the cardiac cycle.
A male client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling he is experiencing worsens at night. What client teaching should the nurse provide?
- A. Elevate the hands on two pillows at night
- B. Notify the healthcare provider as soon as possible
- C. Wear braces as both wrists during the night
- D. Apply cold compresses for 30 minutes before bedtime
Correct Answer: C
Rationale: Wearing wrist braces during the night helps prevent exacerbation of carpal tunnel syndrome symptoms.
An older male client with long-standing lung disease is admitted to the medical unit for treatment of pulmonary infection. In assessing for signs of increasing hypoxia, which action should the nurse include? (select all that apply)
- A. Monitor dryness of mucous membranes
- B. Check for changes in mentation
- C. Observe color of skin and nailbeds
- D. Note appearance of jugular veins
Correct Answer: B
Rationale: Changes in mentation, skin color, and breathing patterns are key indicators of hypoxia in clients with lung disease.
A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?
- A. Prepare for transcutaneous pacing
- B. Deliver another defibrillator shock
- C. Administer IV Epinephrine per ACLS protocol
- D. Give IV dose of adenosine rapidly over 1-2 seconds
Correct Answer: D
Rationale: The client may experience arrhythmia, and the correct intervention is giving IV adenosine to slow the heart rate.
The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?
- A. Collect the blood sample
- B. Assess radial pulse volume
- C. Apply pressure to the site
- D. Select another finger
Correct Answer: A
Rationale: The reddened and engorged appearance is due to increased blood flow, and the sample can still be collected.