Nokea
A client in cardiac arrest shows to be in torsades de pointes, and magnesium sulfate is ordered STAT. The priority nursing intervention is
- A. monitor client for bradycardia and respiratory depression.
- B. prepare client for synchronized cardioversion.
- C. monitor client for tachycardia and hyperventilation.
- D. prepare client for Swan catheter.
Correct Answer: A
Rationale: Magnesium sulfate for torsades de pointes can cause bradycardia and respiratory depression, requiring close monitoring.
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A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication:
- A. Will cause dark staining of the surrounding skin
- B. Produces a cooling sensation when applied
- C. Can alter the function of the thyroid
- D. Produces a burning sensation when applied
Correct Answer: D
Rationale: Sulfamylon (mafenide acetate) causes a burning sensation upon application, which should be explained to the client.
The nurse is inserting an intravenous line into the right arm and has identified a potential insertion site. Place the steps (indicated in Roman numerals) of venipuncture in the proper sequential order.
- A. Palpate vein.
- B. Cleanse skin
- C. Apply tourniquet.
- D. Perform venipuncture.
Correct Answer: C,A,B,D
Rationale: Venipuncture sequence: Apply tourniquet (III), palpate vein (I), cleanse skin (II), perform venipuncture (IV).
The nurse is preparing to hang a unit of blood on a client. The blood has been checked off with two RNs and the pre-infusion vitals recorded. The nurse is at the bedside monitoring the infusion. Shortly after beginning the infusion, the pump alarm sounds. The IV has infiltrated. No blood has yet reached the client. The client is a hard stick, and the nurse realizes that a line cannot be placed within the time frame to begin the infusion. Which action by the nurse is correct?
- A. return the blood and the tubing to the blood bank for storage until an IV can be placed
- B. place the blood bag and tubing in the medication refrigerator until an IV can be restarted
- C. cancel the order for blood and notify the health care provider that the client has no access
- D. wait until 30 minutes has passed while IV placement is attempted, and then waste the blood and chart it as expired
- E. return the blood to the blood bank and notify the next shift when they arrive that they need to start an IV and administer the blood
Correct Answer: C
Rationale: Since no blood reached the client and IV access cannot be re-established within the time frame, the nurse should cancel the order and notify the provider to reassess the need for transfusion.
A client is being discharged with an implantable cardioverter-defibrillator (ICD), and the nurse is educating the client about home management. The client asks what he should do if the ICD fires one time but he has no other symptoms. Which of the following is the best advice?
- A. Call 9-1-1.
- B. Go to the emergency department when recovered from the firing.
- C. Resume normal activities.
- D. Lie down and rest and report the event to the physician by telephone.
Correct Answer: D
Rationale: A single ICD firing without symptoms should be reported to the physician (D) for evaluation. Calling 9-1-1 (A) or going to the ED (B) is unnecessary, and resuming activities (C) may be premature.
The nurse is preparing to walk the postpartum client for the first time since delivery. Before walking the client, the nurse should:
- A. Give the client pain medication
- B. Assist the client in dangling her legs
- C. Have the client breathe deeply
- D. Provide the client additional fluids
Correct Answer: B
Rationale: Dangling the legs before walking helps assess for orthostatic hypotension and ensures the client is stable, reducing the risk of fainting.