Nokea
A client's telemetry monitor displays ventricular tachycardia. Upon reaching the client's bedside, which action should the nurse take first?
- A. Call a code.
- B. Prepare for cardioversion.
- C. Prepare to defibrillate the client.
- D. Check the client's level of consciousness.
Correct Answer: D
Rationale: Determining unresponsiveness is the first assessment action to take. When a client is in ventricular tachycardia, there is a significant decrease in cardiac output. However, assessing for unresponsiveness helps determine whether the client is affected by the decreased cardiac output. If the client is unconscious, then cardiopulmonary resuscitation is initiated.
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A client began receiving an intravenous (IV) infusion of packed red blood cells 30 minutes ago. What is the initial nursing action when the client reports itching and a tight sensation in the chest?
- A. Stop the transfusion.
- B. Check the client's temperature.
- C. Call the primary health care provider.
- D. Recheck the unit of blood for compatibility.
Correct Answer: A
Rationale: The symptoms reported by the client indicate that the client is experiencing a transfusion reaction. The first action of the nurse when a transfusion reaction is observed is to discontinue the transfusion. The IV of normal saline with new IV tubing is started and the primary health care provider is notified. The nurse then checks the client's vital signs: temperature, pulse, and respirations and then rechecks the unit of blood as appropriate for infusion into the client.
Which important parameter should the nurse assess on a daily basis for a client diagnosed with nephrotic syndrome?
- A. Weight
- B. Albumin levels
- C. Activity tolerance
- D. Blood urea nitrogen (BUN) level
Correct Answer: A
Rationale: The client with nephrotic syndrome typically presents with edema, hypoalbuminemia, and proteinuria. The nurse carefully assesses the fluid balance of the client, which includes daily monitoring of weight, intake and output, edema, and girth measurements. Albumin levels are monitored as they are prescribed, as are the BUN and creatinine levels. The client's activity level is adjusted according to the amount of edema and water retention.
A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud's disease. The nurse should assess the trigger of these signs/symptoms by asking which question?
- A. Does being exposed to heat seem to cause the episodes?
- B. Do the signs and symptoms occur while you are asleep?
- C. Does drinking coffee or ingesting chocolate seem related to the episodes?
- D. Have you experienced any injuries that have limited your activity levels lately?
Correct Answer: C
Rationale: Raynaud's disease is vasospasm of the arterioles and arteries of the upper and lower extremities. It produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Episodes are characterized by pallor, cold, numbness, and possible cyanosis of the fingers, followed by erythema, tingling, and aching pain. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress. Prolonged episodes of inactivity are unrelated to these episodes.
The nurse is caring for a client with a nasogastric tube that is attached to low suction. If the client's HCO3- is 30, which additional value is most likely to be noted in this client?
- A. pH 7.52
- B. pH 7.36
- C. pH 7.25
- D. pH 7.20
Correct Answer: A
Rationale: Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of the loss of hydrochloric acid (HCl), an acid secreted in the stomach. This occurs as HCO3 rises above normal. Thus, the loss of hydrogen ions in the HCl results in alkalosis. A pH above 7.45 would be noted.
A client is scheduled for a subtotal gastrectomy (Billroth II procedure). The nurse explains that the procedure will have which surgical results?
- A. Proximal end of the distal stomach is anastomosed to the duodenum.
- B. Entire stomach is removed and the esophagus is anastomosed to the duodenum.
- C. Lower portion of the stomach is removed and the remainder is anastomosed to the jejunum.
- D. Antrum of the stomach is removed and the remaining portion is anastomosed to the duodenum.
Correct Answer: C
Rationale: In the Billroth II procedure, the lower portion of the stomach is removed and the remainder is anastomosed to the jejunum. The duodenal stump is preserved to permit bile flow to the jejunum. Options 1, 2, and 4 are incorrect descriptions.