Nokea
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.
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A 20-year-old male has recently been diagnosed with schizophrenia. The nurse knows which of the following are classic signs and symptoms of this disorder? Select all that apply.
- A. social withdrawal
- B. agitation
- C. auditory hallucinations
- D. disorganized speech
- E. obsession with personal hygiene
Correct Answer: A,C,D
Rationale: Schizophrenia symptoms include social withdrawal, auditory hallucinations, and disorganized speech. Agitation may occur but is less specific, and obsession with hygiene is not typical.
A client is receiving an opioid per patient-controlled analgesia (PCA) pump to control postoperative pain; however, when the nurse assesses the client, she finds the client is pale and hypotensive, and has a respiratory rate of 6 breaths per minute. The PCA pump record shows that the limit for maximum dosage was set far too high, resulting in an overdose. The client is very somnolent and barely responsive. What interventions does the nurse anticipate? Select all that apply.
- A. Immediately stop the infusion.
- B. Discontinue the PCA pump.
- C. Administer naloxone per standing orders.
- D. Administer supplementary oxygen.
- E. File an incident report.
Correct Answer: A,C,D,E
Rationale: Opioid overdose requires stopping the infusion (A), administering naloxone (C) to reverse effects, providing oxygen (D) for respiratory depression, and filing an incident report (E). Discontinuing the PCA (B) is not immediate.
The nurse is assessing a client with an altered level of consciousness. One of the first signs of altered level of consciousness is:
- A. Inability to perform motor activities
- B. Complaints of double vision
- C. Restlessness
- D. Unequal pupil size
Correct Answer: C
Rationale: Restlessness is often an early sign of altered consciousness, indicating neurological changes before more severe symptoms appear.
The nurse finds that a client receiving digoxin (Lanoxin) 0.25 mg orally has an apical pulse of 54. Which of the following should the nurse do first?
- A. withhold the medicine and contact the prescribing physician
- B. ask another nurse to verify the apical pulse
- C. administer the medication and recheck the pulse in 30 minutes
- D. order a stat ECG
Correct Answer: A
Rationale: An apical pulse of 54 is below the safe threshold (typically 60) for digoxin, indicating potential toxicity. Withholding the dose and notifying the provider is the priority.
A home health nurse is visiting a client who is receiving diuretic therapy for congestive heart failure. Which medication places the client at risk for the development of hypokalemia?
- A. Aldactone (spironolactone)
- B. Demadex (torsemide)
- C. Dyrenium (triamterene)
- D. Midamor (amiloride hydrochloride)
Correct Answer: B
Rationale: Demadex, a loop diuretic, causes potassium loss, increasing the risk of hypokalemia, unlike potassium-sparing diuretics like Aldactone.