Nokea
A client experiences initial indications of excitation after having an I.V. infusion of lidocaine hydrochloride started. The nurse should further assess the client when the client reports having:
- A. Palpitations.
- B. Tinnitus.
- C. Urinary frequency.
- D. Lethargy.
Correct Answer: B
Rationale: Tinnitus is a sign of lidocaine toxicity, requiring further assessment to prevent serious complications like seizures or arrhythmias.
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On the day of surgery, a client with diabetes who takes insulin on a sliding scale is ordered to have nothing by mouth and all medications withheld. The client's 6 a.m. glucose level is 300 mg/dL. The nurse should:
- A. Withhold all medications as ordered.
- B. Administer the insulin dose dictated by the sliding scale.
- C. Call the physician for specific orders based on the glucose level.
- D. Notify the surgery department.
Correct Answer: C
Rationale: A glucose level of 300 mg/dL indicates significant hyperglycemia, which poses risks during surgery. Calling the physician for specific orders ensures appropriate insulin administration while adhering to NPO and surgical protocols.
The nurse is applying a hand mitt restraint for a client with pruritis (see figure). The nurse should be:
- A. Verify the physician order to use the restraint.
- B. Secure the mitt with ties around the wrist tied to the bed frame.
- C. Place a folded pillow under the wrist.
- D. Place the mitt on top of the hand.
Correct Answer: A
Rationale: A physician's order is required for restraints to ensure legal and ethical use, prioritizing patient safety and preventing scratching in pruritus.
Blood pressure in the systemic circulation is highest in the:
- A. Arterioles
- B. Capillaries
- C. Aorta
- D. Venules
Correct Answer: C
Rationale: Blood pressure is highest in the aorta, where blood is ejected directly from the left ventricle during systole, generating peak pressure (systolic pressure). As blood flows through arterioles, capillaries, and venules, pressure progressively decreases due to resistance and vessel compliance. This makes the aorta the correct answer.
The nurse is assessing a client who has had a myocardial infarction. The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifies this rhythm as which of the following?
- A. Atrial fibrillation.
- B. Ventricular tachycardia.
- C. Premature ventricular contractions.
- D. Sinus tachycardia.
Correct Answer: D
Rationale: Sinus tachycardia is a fast but regular rhythm originating from the sinoatrial node, typically occurring in response to factors like pain, fever, anxiety, or myocardial infarction.
Sensorineural hearing loss results from which of the following conditions?
- A. Presence of fluid and cerumen in the external canal.
- B. Sclerosis of the bones of the middle ear.
- C. Change to the cochlear or vestibulocochlear nerve.
- D. Emotional disturbance resulting in a functional hearing loss.
Correct Answer: C
Rationale: Sensorineural hearing loss results from damage to the cochlear or vestibulocochlear nerve, affecting the inner ear or neural pathways.