Nokea
A client in the ICU is given procainamide HCl (Pronestyl) slowly IV push. The nurse should withhold the next dose if which of the following was observed?
- A. Presence of premature ventricular contractions.
- B. Occurrence of severe hypotension.
- C. Recurring paroxysmal atrial tachycardia.
- D. A sedimentation rate of 10.
Correct Answer: B
Rationale: Procainamide treats ventricular and atrial arrhythmias, but severe hypotension is an adverse reaction requiring the dose to be withheld. PVCs (A) and atrial tachycardia (C) are indications for use, and a normal sedimentation rate (D) is irrelevant.
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A nurse is assessing a newborn who is 1 hour old. Which of the following findings should be reported to the healthcare provider? (Select all that apply)
- A. Respiratory rate of 50 breaths per minute
- B. Nasal flaring
- C. Grunting
- D. Temperature of 36.5°C (97.7°F)
Correct Answer: B,C
Rationale: Nasal flaring and grunting indicate respiratory distress, requiring immediate reporting. A respiratory rate of 50 and temperature of 36.5°C are normal for a newborn.
Steatorrhea:
Steatorrhea:
- A. Greasy stools
- B. Loose, frequent bowel movement
- C. Constipation
- D. Melena
Correct Answer: A
Rationale: Steatorrhea involves greasy, fatty stools due to fat malabsorption.
As a general guide for emergency management of acute alcohol intoxication, it is important for the nurse initially to obtain data regarding which of the following?
- A. What and how much the client drinks, according to family and friends
- B. The blood alcohol level of the client
- C. The blood pressure level of the client
- D. The blood glucose level of the client
Correct Answer: B
Rationale: Blood alcohol levels are generally obtained to determine the level of intoxication. The amount of alcohol consumed determines how much medication the client needs for detoxification and treatment. Reports of alcohol consumption are notoriously inaccurate.
A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:
- A. assessment.
- B. crisis intervention.
- C. empathetic concern.
- D. unwarranted intrusion.
Correct Answer: B
Rationale: Counseling by a rape crisis nurse specialist is a form of crisis intervention, providing immediate support to address the trauma. It is not merely assessment, empathy, or intrusion. Coordinated Care
A client with Anemia has been prescribed liquid iron. Which would the nurse expect to be included in the teaching plan?
- A. Take the medication through a straw.
- B. Administer this drug mixed with coffee.
- C. The drug causes the urine to turn black.
- D. The drug must be stored in the refrigerator.
Correct Answer: A
Rationale: Liquid iron should be administered through a straw to prevent dental staining. Answers B, C, and D are not correct instructions for taking liquid iron, so they are incorrect.