Nokea
A client has a rate-responsive permanent pacemaker in his upper chest. The nurse understands rate-responsive to mean which of the following?
- A. A pacemaker function prevents excessive changes in the pacing rate.
- B. The pacing rate increases above the normal pacing rate with sudden bradycardia.
- C. The pacemaker switches from atrial tracking mode to nontracking mode with atrial fibrillation.
- D. The pacing rate increases when the sensors note increased activity.
Correct Answer: D
Rationale: A rate-responsive pacemaker increases the pacing rate when sensors detect increased activity (D), mimicking normal heart rate response. Other options (A, B, C) describe different pacemaker functions.
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Which assignment should not be performed by the nursing assistant?
- A. Feeding the client
- B. Bathing the client
- C. Obtaining a stool
- D. Administering a fleet enema
Correct Answer: D
Rationale: Administering an enema is an invasive procedure requiring clinical judgment, which is beyond the scope of a nursing assistant's responsibilities.
A 5-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on:
- A. Preventing infection
- B. Administering antipyretics
- C. Keeping the skin free of moisture
- D. Limiting oral fluid intake
Correct Answer: A
Rationale: Atopic dermatitis involves inflamed skin prone to infection, so preventing infection through gentle skin care and monitoring is a priority.
A nurse prepares to administer a transfusion of RBCs and takes the client's vital signs. The client's temperature is 102.7°F, but other vitals are within normal limits. The nurse should
- A. transfuse the RBC as ordered.
- B. administer an antipyretic and transfuse the RBCs.
- C. transfuse the RBCs but monitor the temperature hourly.
- D. not transfuse the RBCs and instead contact the physician.
Correct Answer: D
Rationale: Fever (102.7°F) may indicate an infection or transfusion reaction risk. The physician should be contacted before proceeding with the transfusion.
During a unit card game, a client with acute mania begins to sing loudly as she starts to undress. The nurse should:
- A. Ignore the client's behavior
- B. Exchange the cards for a checker board
- C. Send the other clients to their rooms
- D. Cover the client and walk her to her room
Correct Answer: D
Rationale: Covering the client and escorting her to a private area maintains dignity and safety, addressing the inappropriate behavior calmly.
A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with:
- A. Magnesium sulfate
- B. Calcium gluconate
- C. Dinoprostone (Prostin E.)
- D. Bromocrystine (Parlodel)
Correct Answer: C
Rationale: Dinoprostone is used to induce uterine contractions and facilitate expulsion in a missed abortion.