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A client with a history of atrial fibrillation is admitted with a heart rate of 160 beats per minute. The nurse should prioritize which of the following interventions?
- A. Administer diltiazem as prescribed.
- B. Obtain a 12-lead ECG.
- C. Administer aspirin.
- D. Apply oxygen via nasal cannula.
Correct Answer: A
Rationale: Diltiazem, a calcium channel blocker, is prioritized to control rapid heart rate in atrial fibrillation.
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A client with a history of chronic kidney disease is prescribed furosemide (Lasix). The nurse should monitor the client for which of the following electrolyte imbalances? Select all that apply.
- A. Hypokalemia.
- B. Hyponatremia.
- C. Hypomagnesemia.
- D. Hypercalcemia.
- E. Hypophosphatemia.
Correct Answer: A, B, C
Rationale: Furosemide can cause hypokalemia, hyponatremia, and hypomagnesemia due to electrolyte loss.
The nurse is teaching a client with a new diagnosis of type 1 diabetes mellitus about insulin administration. Which of the following instructions is most important?
- A. Rotate injection sites.
- B. Store insulin in the freezer.
- C. Administer insulin at bedtime only.
- D. Use the same syringe for multiple doses.
Correct Answer: A
Rationale: Rotating injection sites prevents lipodystrophy and ensures consistent insulin absorption.
The home health nurse cares for an obese adult client. In the client's medical record, the nurse reads, 'The client has a sprained right ankle, has not exercised for more than 1 week, and has missed the last two physical therapy appointments.' The client says, 'I attend therapy for my ankle and I do my exercises three times a day.' Which response should the nurse use with the client?
- A. Show me the exercises that you perform in physical therapy.
- B. You will never heal if you skip the physical therapy sessions.
- C. Your progress sounds fine. Is more physical therapy scheduled?
- D. I see that you missed the last two physical therapy appointments.
Correct Answer: D
Rationale: In the correct option, the nurse employs the therapeutic communication technique of confrontation. Because the client is employing avoidance, the nurse presents the facts according to the medical record to assess the client's perspective without accusing, threatening, or humiliating the client about the missed physical therapy. By confronting, the nurse assists the client with problem-solving. Option 1 is potentially helpful when the client is complying with therapy. In option 2, the nurse provides an opinion and this statement admonishes the client for the behavior. In option 3, the nurse is nontherapeutic in giving approval and is mirroring the client's avoidance and passivity by not dealing directly with the problem of missed appointments.
When teaching unlicensed assistive personnel (UAP) about the importance of hand washing in preventing disease, the nurse should instruct the UAP that?
- A. It is not necessary to wash your hands as long as you use gloves.'
- B. Handwashing is the best method for preventing cross-contamination.'
- C. Waterless commercial products are not effective for killing organisms.'
- D. The hands do not serve as a source of infection.'
Correct Answer: B
Rationale: Handwashing is the most effective method to prevent cross-contamination, as hands are a primary source of infection transmission in healthcare settings.
A nurse is assessing an 82-year-old for depression, because of the client's age, the nurses' assessment should be guided by the fact that:
- A. Sadness of mood is usually present but it is masked by other symptoms.
- B. Impairment of cognition usually is not present.
- C. Psychosomatic tendencies do not tend to dominate.
- D. Antidepressant therapies are less effective in older adults.
Correct Answer: A
Rationale: In older adults, depression may present with atypical symptoms, such as somatic complaints or irritability, rather than overt sadness, which can mask the condition.