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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Which of the following actions should the student nurse complete FIRST?
- A. Take an axillary temperature to minimize use of invasive procedures.
- B. Count respirations for 15 seconds and multiply the number by 4.
- C. Count respirations for a minute prior to arousing the infant.
- D. Use a stethoscope with a one-and-a-half-inch diaphragm to count the apical pulse.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) inappropriate to use probe to take axillary temperature (2) should count for a full minute (3) correct-respirations should be counted for one full minute prior to arousing the infant with a temperature probe or stethoscope (4) after infant is stimulated, crying may interfere with accurate evaluation of respirations
Which statement by the nurse is appropriate when giving an assignment to an unlicensed assistive personnel (UAP) to help a client ambulate for the first time after a colon resection?
- A. Have the client sit on the side of the bed before helping the client to walk.
- B. If the client is dizzy ask the client to take some slow, deep breaths.
- C. Help the client to walk in the room as often as the client wishes.
- D. When you help the client to walk, ask if any pain occurs.
Correct Answer: A
Rationale: This statement gives clear directions to the UAP about the task and is most closely associated with the information provided in the stem that this is the client's first time out of bed after surgery.
An older adult is diagnosed with Parkinson's disease. The client asks the nurse what causes Parkinson's disease. In addition to telling the client that we are not really sure what causes it, the nurse should include which information?
- A. There is not enough dopamine in the brain.
- B. The myelin sheath is being destroyed.
- C. There is not enough acetylcholine at the myoneural junction.
- D. There is an obstruction in the circulation of the brain.
Correct Answer: A
Rationale: Parkinson's disease results from dopamine deficiency in the basal ganglia, impairing movement, unlike myelin destruction, acetylcholine issues, or circulatory obstruction.
A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When planning client teaching, what is most important for the nurse to emphasize?
- A. Maintain a low sodium diet
- B. Take a diuretic with lithium and avoid excessive fluids
- C. Don't be overly concerned if feelings of depression occur
- D. Come in for evaluation of serum lithium levels regularly
Correct Answer: D
Rationale: Come in for evaluation of serum lithium levels regularly. Regular monitoring prevents toxicity, especially during conditions like hot weather that affect sodium levels.
A client in the intensive care unit is overheard telling his wife, 'It's impossible to get any sleep in this place with all the noise and lights on all the time.' After talking with the client, the nurse determines that the client is bothered by sensory disturbance related to being in the ICU. Which laboratory finding would confirm the nurse's assessment of sensory disturbance?
- A. Increased urine catecholamines
- B. Decreased TSH
- C. Erratic changes in BUN levels
- D. Increased blood glucose levels
Correct Answer: A
Rationale: Sensory disturbance and stress in the ICU increase catecholamines (e.g., epinephrine), detectable in urine. Other labs are unrelated to sensory disturbance.