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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A patient is scheduled for electro-convulsive therapy treatment scheduled in the morning. What must the evening nurse do to provide the client ECT treatment possible?
- A. Patient signs an informed consent form
- B. Patient is given morning medications
- C. Patient gets a good night's sleep
- D. Patient has a good breakfast
Correct Answer: A
Rationale: An informed consent is required prior to surgery.
An adult is admitted with probable pulmonary tuberculosis. Which findings would the nurse expect to be present in this client? Select all that apply.
- A. High fevers in the morning
- B. Cough
- C. Bloody sputum
- D. Night sweats
- E. Weight gain
- F. Malaise
Correct Answer: B,C,D,F
Rationale: Tuberculosis causes chronic cough, hemoptysis (bloody sputum), night sweats, and malaise due to systemic infection. Fevers are typically low-grade and nocturnal, and weight loss, not gain, is common.
If a very active two year-old client pulls his tunneled central venous catheter out, what initial nursing action is appropriate?
- A. Obtain emergency equipment
- B. Assess heart rate, rhythm and all pulses
- C. Apply pressure to the vessel insertion site
- D. Use cold packs at the exit incision site
Correct Answer: C
Rationale: If a central venous catheter is accidentally removed, pressure should be applied to the vein entry site to prevent bleeding and complications.
Which characteristic is most likely to be present in persons who abuse others?
- A. Financial security
- B. Positive self-image
- C. Substance abuse
- D. Physical illness
Correct Answer: C
Rationale: Substance abuse is strongly associated with abusive behavior due to impaired judgment and aggression. Financial security, self-image, or illness are less predictive.
The nurse is teaching parents of an infant about introduction of solid food to their baby. What is the first food they can add to the diet?
- A. Vegetables
- B. Cereal
- C. Fruit
- D. Meats
Correct Answer: B
Rationale: Cereal is usually introduced first because it is well tolerated, easy to digest, and contains iron.