Nokea
A nurse assesses an older adult client who has multiple chronic diseases. The client’s heart rate is 48 beats/min. Which action should the nurse take first?
- A. Document the finding in the chart.
- B. Initiate external pacing.
- C. Assess the client’s medications.
- D. Administer 1 mg of atropine.
Correct Answer: C
Rationale: A heart rate of 48 beats/min (bradycardia) in an older adult with multiple chronic diseases may be due to medication side effects. Assessing the client’s medications is the first step to determine if any drugs are contributing to the bradycardia.
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The following are examples of acquired heart disease. Select all that apply.
- A. Infective endocarditis
- B. Coarctation of the aorta
- C. Rheumatic fever (RF)
- D. Cardiomyopathy
Correct Answer: C
Rationale: Acquired heart diseases include conditions that develop after birth, such as infective endocarditis, rheumatic fever, cardiomyopathy, and Kawasaki disease. Coarctation of the aorta and transposition of the great vessels are congenital heart defects.
When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?
- A. Daily weight
- B. Vital signs
- C. Level of consciousness
- D. Bowel sounds
Correct Answer: A
Rationale: Daily weight is crucial in monitoring fluid balance in clients with nephrotic syndrome, as they are prone to edema.
Hypoglycemia in an infant is defined as whole blood glucose level less than
- A. 40 mg/dl
- B. 50 mg/dl
- C. 60 mg/dl
- D. 80 mg/dl
Correct Answer: A
Rationale: Hypoglycemia in infants is defined as a whole blood glucose level less than 40 mg/dl, as this threshold is critical for brain function.
Causes of non-bloody diarrhoea include:
- A. Shigella dysentery
- B. Campylobacter jejuni
- C. Giardia lamblia
- D. Salmonella
Correct Answer: C
Rationale: Giardia lamblia is a common cause of non-bloody diarrhoea. Shigella and Campylobacter typically cause bloody diarrhoea.
The nurse is teaching the importance of an exercise regime that includes walking daily for a group of clients with asthma, chronic bronchitis, and emphysema at a pulmonary rehabilitation clinic. Which rationale should the nurse include when motivating the clients?
- A. Daily exercise and walking enhances cardiovascular fitness
- B. Exercise eliminates the need for bronchodilator medications.
- C. Walking daily reverses lung damage caused by chronic conditions.
- D. Physical activity increases mucus production to clear airways.
Correct Answer: A
Rationale: Regular exercise improves cardiovascular fitness, which can enhance overall respiratory function and quality of life in clients with chronic pulmonary conditions.