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A client who has been given cardiopulmonary resuscitation (CPR) is transported by ambulance to the hospital's emergency department, where the admitting nurse quickly assesses the client's condition. The most effective way to determine the effectiveness of CPR is noting whether the:
- A. Pulse rate is normal.
- B. Pupils are reacting to light.
- C. Mucous membranes are pink.
- D. Systolic blood pressure is at least 80 mm Hg.
Correct Answer: D
Rationale: A systolic blood pressure of at least 80 mm Hg indicates effective CPR, as it reflects adequate circulation and perfusion.
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The family of a client in hospice asks about stopping oral feedings. The nurse should explain that:
- A. Stopping feedings may reduce discomfort.
- B. Feedings must continue to prevent starvation.
- C. Oral feedings are required by law.
- D. Stopping feedings will hasten death.
Correct Answer: A
Rationale: Stopping oral feedings in hospice can reduce discomfort from fluid overload or aspiration, aligning with comfort-focused care.
Which medication requires monitoring for a client with Parkinson's disease?
- A. Antihypertensives.
- B. Levodopa.
- C. Antidepressants.
- D. Antihistamines.
Correct Answer: B
Rationale: Levodopa requires monitoring for efficacy and side effects, as it is a primary treatment for Parkinson's symptoms.
A female receiving radiation therapy for lung cancer complains to the nurse that she is having difficulty sleeping. Which of the following nursing actions is most appropriate?
- A. Suggest the client stop watching television before bed.
- B. Assess the client's usual sleep patterns, amount of sleep, and bedtime rituals.
- C. Tell the client sleeplessness is expected with radiation therapy.
- D. Suggest that the client stop drinking coffee until the therapy is completed.
Correct Answer: B
Rationale: Assessing sleep patterns, amount of sleep, and bedtime rituals provides a comprehensive understanding of the client's insomnia, enabling tailored interventions.
An 82-year-old female has several ecchymotic areas on her left arm. The nurse should further assess the client for:
- A. Elder abuse.
- B. Self-inflicted injury.
- C. Increased capillary fragility and permeability.
- D. Increased blood supply to the skin.
Correct Answer: C
Rationale: Aging increases capillary fragility and permeability, leading to easy bruising (ecchymosis). While elder abuse is possible, capillary fragility is the most likely cause in this context.
Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the drug when chest pain occurs?
- A. Take one tablet every 2 to 5 minutes until the pain stops.
- B. Take one tablet and rest for 10 minutes. Call the physician if pain persists after 10 minutes.
- C. Take one tablet, then an additional tablet every 5 minutes for a total of three tablets. Call the physician if pain persists after three tablets.
- D. Take one tablet. If pain persists after 5 minutes, take two tablets. If pain still persists 5 minutes later, call the physician.
Correct Answer: C
Rationale: Standard protocol for sublingual nitroglycerin is one tablet every 5 minutes for up to three doses. If pain persists, the client should seek medical help.