Nokea
A client with an implantable cardioverter defibrillator (ICD) develops ventricular tachycardia (VT) with a pulse while admitted to the medical-surgical unit. The ICD fires multiple times without successfully stopping the VT, causing the client to become confused and difficult to rouse. Which action by the nurse is appropriate?
- A. Attempt to stimulate a vagal response by having the client cough
- B. Deactivate the client's implantable cardioverter defibrillator with an external magnet
- C. Obtain a STAT 12-lead ECG to verify the cardiac rhythm
- D. Prepare for synchronized cardioversion with the external defibrillator
Correct Answer: D
Rationale: Persistent VT causing altered mental status requires synchronized cardioversion to restore normal rhythm.
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The pediatric nurse is reinforcing education about medication administration to the parents of a 4-year-old client. Which statements made by the parents demonstrate correct understanding? Select all that apply.
- A. I can mix the medication in a bowl of my child's favorite cereal.
- B. I should give another dose if my child vomits after taking the medication.
- C. I should measure liquid medications using an oral syringe.
- D. I will encourage my child to help me as I prepare the medication.
- E. I will place my child in time-out if the medication is refused.
Correct Answer: C
Rationale: Using an oral syringe ensures accurate dosing. Mixing with food, redosing after vomiting, involving the child in preparation, or punishing refusal are inappropriate.
The health care provider has prescribed spironolactone to be given in addition to hydrochlorothiazide to a client with hypertension. Which finding by the nurse indicates that the spironolactone is having the desired effect?
- A. Blood glucose of 95 mg/dL (5.3 mmol/L)
- B. Potassium level of 4.2 mEq/L (4.2 mmol/L)
- C. Reduction in dizziness
- D. Sodium level of 138 mEq/L (138 mmol/L)
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic, so a normal potassium level indicates it is counteracting the potassium loss from hydrochlorothiazide.
The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching?
- A. The axillary pads are torn and show signs of wear
- B. The client has a 30-degree bend at the elbow when walking
- C. The crutches and injured foot are moved simultaneously in a 3-point gait
- D. There is a 3 finger-width space noted between the axilla and axillary pad
Correct Answer: A
Rationale: Torn axillary pads can cause discomfort and injury, indicating a need for replacement and further teaching.
The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal?
- A. Antabuse (disulfiram)
- B. Romazecon (flumazenil)
- C. Dolophine (methodone)
- D. Ativan (lorazepam)
Correct Answer: D
Rationale: Ativan (lorazepam), a benzodiazepine, is used to manage alcohol withdrawal symptoms like seizures and agitation. Antabuse deters drinking, flumazenil reverses benzodiazepines, and methadone treats opioid withdrawal.
The nurse is talking with the parent of a 1-day-old female client who has a small amount of blood-tinged, mucoid vaginal drainage. Which of the following statements would be most appropriate for the nurse to make?
- A. Laboratory tests will need to be performed to determine your baby's hormone levels.
- B. The health care provider will prescribe a medication to stop the bleeding.
- C. We will continue to monitor the amount, color, and consistency of the drainage.
- D. What visitors have been present since your baby was born?
Correct Answer: C
Rationale: Blood-tinged vaginal drainage in a newborn is often due to maternal hormone exposure and typically resolves. Monitoring is appropriate.