Nokea
A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?
- A. Prepare for transcutaneous pacing
- B. Deliver another defibrillator shock
- C. Administer IV Epinephrine per ACLS protocol
- D. Give IV dose of adenosine rapidly over 1-2 seconds
Correct Answer: D
Rationale: The client may experience arrhythmia, and the correct intervention is giving IV adenosine to slow the heart rate.
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A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse?
- A. Elevated temperature
- B. Generalized weakness
- C. Diminished lung sounds
- D. Pain when swallowing
Correct Answer: D
Rationale: Pain when swallowing could indicate an opportunistic infection such as candidiasis, which requires prompt treatment.
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take?
- A. Elevate the leg and apply a sandbag to the entrance site.
- B. Increase the flow rate of intravenous fluids.
- C. Assess the color and temperature of the left leg.
- D. Document the finding as the left pedal pulse of +1/4.
Correct Answer: C
Rationale: A weak pedal pulse after cardiac angiography may indicate compromised blood flow. Assessing the color and temperature of the leg helps determine if there is ischemia or other complications.
A child with rheumatic fever begins involuntary, purposeless movements of her limbs. What does the nurse recognize that this indicates?
- A. Seizure activity
- B. Hypoxia
- C. Sydenham’s chorea
- D. Decreasing level of consciousness
Correct Answer: C
Rationale: As the effects of rheumatic fever affect the central nervous system, the child may develop Sydenham’s chorea, manifested by involuntary, purposeless movements of the limbs.
In neonates with anomalous total pulmonary venous return and obstruction, the chest x-ray demonstrates
- A. heart enlarged
- B. prominent pulmonary artery
- C. prominent right ventricle
- D. prominent subaortic stenosis
Correct Answer: D
Rationale: Prominent subaortic stenosis is not typically seen in TAPVR.
A nurse is caring for a child with a diagnosis of Kawasaki disease. Which of the following is a common complication of this disease?
- A. Pulmonary hypertension
- B. Aneurysms of the coronary arteries
- C. Diabetes mellitus
- D. Ventricular arrhythmias
Correct Answer: B
Rationale: Aneurysms of the coronary arteries are a common and serious complication of Kawasaki disease.