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A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?
- A. Defibrillation
- B. Administer oxygen
- C. Call for help
- D. Start chest compressions
Correct Answer: A
Rationale: The correct answer is A: Defibrillation. Ventricular fibrillation is a life-threatening arrhythmia that requires immediate defibrillation to restore the heart's normal rhythm. Defibrillation is the priority as it is the most effective intervention to treat ventricular fibrillation and increase the chance of survival. Administering oxygen (B) is important but not the priority over defibrillation. Calling for help (C) should be done after initiating defibrillation. Starting chest compressions (D) should only be done if defibrillation is not immediately available or unsuccessful.
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A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?
- A. Bronchoscopy
- B. Chest X-ray
- C. TB skin test (Mantoux test)
- D. Sputum culture for acid-fast bacillus
Correct Answer: D
Rationale: The correct answer is D: Sputum culture for acid-fast bacillus. This test is the most reliable for confirming active pulmonary TB because it directly detects the presence of the Mycobacterium tuberculosis bacteria in the sputum sample. Bronchoscopy (A) may help visualize the airways but does not definitively confirm TB. Chest X-ray (B) can show characteristic findings suggestive of TB but cannot confirm the diagnosis. TB skin test (C) indicates exposure but not active disease. Sputum culture is the gold standard for diagnosing TB, as it allows for definitive identification of the bacteria.
A nurse is assessing a client with menopausal symptoms considering hormone therapy. What is a contraindication?
- A. History of osteoporosis
- B. History of breast cancer
- C. History of anemia
- D. History of chronic migraines
Correct Answer: B
Rationale: The correct answer is B: History of breast cancer. Hormone therapy can potentially stimulate the growth of breast cancer cells. It is contraindicated in clients with a history of breast cancer due to the increased risk of cancer recurrence or progression. Other choices are incorrect because: A: History of osteoporosis is not a contraindication for hormone therapy, as it can actually help improve bone density. C: History of anemia is not a contraindication for hormone therapy. D: History of chronic migraines is not a contraindication, but it may need monitoring as hormone therapy can sometimes trigger migraines.
A client is receiving treatment for stage IV ovarian cancer and asks the nurse to discuss her prognosis. The client plans to have aggressive surgical, radiation, and chemotherapy treatments. Which of the following prognoses should the nurse discuss with the client?
- A. Poor
- B. Favorable
- C. Uncertain
- D. Excellent
Correct Answer: A
Rationale: The correct answer is A: Poor. In stage IV ovarian cancer, the cancer has spread beyond the ovaries to distant organs, resulting in a poor prognosis. The aggressive treatments may help manage symptoms and prolong survival but the overall prognosis remains poor due to the advanced stage of the cancer. Choice B (Favorable) is incorrect because stage IV ovarian cancer has a poor prognosis. Choice C (Uncertain) is incorrect as the prognosis for stage IV ovarian cancer is generally known to be poor. Choice D (Excellent) is incorrect as stage IV ovarian cancer is not associated with an excellent prognosis due to its advanced stage.
A nurse is teaching a client about the causes of osteoporosis. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis?
- A. Thyroid hormones
- B. Antihypertensives
- C. Steroids
- D. Insulin
Correct Answer: C
Rationale: The correct answer is C: Steroids. Steroids, specifically glucocorticoids, are known to increase the risk of osteoporosis by decreasing bone formation and increasing bone resorption. Long-term use of steroids can lead to bone loss, making individuals more susceptible to fractures. Thyroid hormones (A) do not directly cause osteoporosis. Antihypertensives (B) and insulin (D) are not associated with increased risk of osteoporosis.
A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?
- A. Establish the ability to communicate effectively.
- B. Increase mobility on the affected side.
- C. Increase independence in activities of daily living.
- D. Prevent falls during rehabilitation.
Correct Answer: A
Rationale: The correct answer is A: Establish the ability to communicate effectively. Communication is a key aspect affected by left hemispheric CVA, which can lead to aphasia or difficulty in speaking and understanding language. By prioritizing communication goals, the nurse can enhance the client's quality of life, facilitate social interactions, and improve overall rehabilitation outcomes. Increasing mobility (B) and independence in activities of daily living (C) are important but may not directly address the communication deficits. Preventing falls (D) is also crucial but not specific to the client's primary deficit.