Nokea
A 62-year-old male client with a history of coronary artery disease complains that his heart is 'racing' and he often feels dizzy. His blood pressure is 110/60, and he uses portable oxygen at 2 liters per nasal cannula. Based on the rhythm shown, which prescription should the nurse administer?
- A. Give magnesium via secondary infusion.
- B. Initiate IV heparin solution as per protocol.
- C. Administer IV adenosine (Adenocard).
- D. Prepare for synchronized cardioversion.
Correct Answer: C
Rationale: The correct answer is C: Administer IV adenosine (Adenocard).
Rationale:
1. The ECG rhythm shows regular narrow complex tachycardia, likely supraventricular tachycardia (SVT).
2. Adenosine is the first-line medication for terminating SVT by blocking conduction through the AV node.
3. Adenosine is given rapidly as a bolus dose followed by a saline flush to ensure quick delivery to the heart.
4. Adenosine has a very short half-life, making it safe to use in this scenario.
Summary:
A: Magnesium is not the first-line treatment for SVT.
B: Heparin is not indicated for the management of SVT.
D: Synchronized cardioversion is reserved for unstable patients with hemodynamic compromise, not indicated for stable SVT.
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A client receiving total parenteral nutrition (TPN) through a central line suddenly develops dyspnea, chest pain, and a drop in blood pressure. What should the nurse do first?
- A. Stop the TPN infusion.
- B. Notify the healthcare provider.
- C. Place the client in Trendelenburg position.
- D. Administer oxygen at 2 liters/minute.
Correct Answer: C
Rationale: The correct answer is C: Place the client in Trendelenburg position. This is the first action to take in a client with suspected air embolism, a potential complication of central line insertion. Placing the client in Trendelenburg position with the head down and the legs elevated can help prevent air from reaching the heart and lungs. This action can help stabilize the client's condition before further interventions can be implemented.
Stopping the TPN infusion (choice A) can be important, but the priority in this situation is to address the potential air embolism. Notifying the healthcare provider (choice B) can be done after the immediate intervention. Administering oxygen (choice D) is important, but placing the client in Trendelenburg position takes precedence in this emergency situation.
The client has acute pancreatitis. Which nursing intervention is the highest priority?
- A. Administer pain medication as prescribed.
- B. Monitor the client's serum amylase and lipase levels.
- C. Encourage oral intake of clear liquids.
- D. Assess the client's bowel sounds every 4 hours.
Correct Answer: A
Rationale: The correct answer is A: Administer pain medication as prescribed. This is the highest priority because acute pancreatitis is a painful condition, and managing pain is crucial for the client's comfort and well-being. Pain control also helps reduce stress on the pancreas and can aid in preventing complications.
Choice B is incorrect because while monitoring serum amylase and lipase levels is important in diagnosing pancreatitis and assessing response to treatment, it is not the highest priority intervention.
Choice C is incorrect as encouraging oral intake of clear liquids may exacerbate pancreatitis symptoms and lead to further complications.
Choice D is incorrect as assessing bowel sounds, while important for monitoring gastrointestinal function, is not the highest priority in the acute management of pancreatitis.
The client with chronic kidney disease (CKD) is receiving hemodialysis. Which finding should be reported to the healthcare provider immediately?
- A. Blood pressure of 150/90 mm Hg.
- B. Weight gain of 2 pounds since the last dialysis session.
- C. Blood glucose level of 120 mg/dl.
- D. Potassium level of 6.5 mEq/L.
Correct Answer: D
Rationale: The correct answer is D: Potassium level of 6.5 mEq/L. High potassium levels (hyperkalemia) in CKD patients receiving hemodialysis can lead to serious complications like cardiac arrhythmias or even cardiac arrest. Therefore, it is crucial to report this finding immediately to the healthcare provider for prompt intervention.
Explanation for other choices:
A: Blood pressure of 150/90 mm Hg - While elevated, this blood pressure reading is not an immediate concern unless accompanied by symptoms like chest pain or shortness of breath.
B: Weight gain of 2 pounds since the last dialysis session - While weight gain may indicate fluid retention, it is not an urgent issue unless it is rapid and significant.
C: Blood glucose level of 120 mg/dl - A blood glucose level of 120 mg/dl is within the normal range and does not require immediate action in this context.
The healthcare provider is planning care for a non-potty-trained child with nephrotic syndrome. Which intervention provides the best means of determining fluid retention?
- A. Weigh the child daily.
- B. Observe the lower extremities for pitting edema.
- C. Measure the child's abdominal girth weekly.
- D. Weigh the child's wet diapers.
Correct Answer: A
Rationale: The correct answer is A: Weigh the child daily. Daily weight monitoring is the most accurate way to determine fluid retention in a child with nephrotic syndrome as it provides real-time data on fluid status. Weight gain is a key indicator of fluid retention in these patients. Observing lower extremities for pitting edema (B) is subjective and may not accurately reflect fluid status. Measuring abdominal girth weekly (C) may not provide timely information on fluid retention. Weighing wet diapers (D) does not give a comprehensive picture of total fluid retention and may not be as accurate as daily weight monitoring.
A recently widowed middle-aged female client presents to the psychiatric clinic for evaluation and tells the nurse that she has 'little reason to live.' She describes one previous suicidal gesture and admits to having a gun in her home. To maintain the client's confidentiality and to help ensure her safety, which action is best for the nurse to implement?
- A. Encourage the client to remove the gun from her possession.
- B. Notify the client's healthcare provider of the availability of the weapon.
- C. Contact a person of the client's choosing to remove the weapon from the home.
- D. Call the local police department and have the weapon removed from the home.
Correct Answer: C
Rationale: The correct answer is C: Contact a person of the client's choosing to remove the weapon from the home. This option respects the client's autonomy and confidentiality while ensuring her safety.
1. Encouraging the client to remove the gun (Option A) may not guarantee immediate action and could potentially escalate the situation.
2. Notifying the client's healthcare provider (Option B) could breach confidentiality and may not result in immediate intervention.
3. Calling the police (Option D) could lead to a loss of trust and may not be necessary if the situation can be handled discreetly by someone the client trusts.
Therefore, option C is the best course of action as it respects the client's autonomy, maintains confidentiality, and ensures prompt removal of the weapon to enhance the client's safety.