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A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client's pulse and respirations, what should be the function of the second nurse?
- A. Relieve the nurse performing CPR
- B. Go get the code cart
- C. Participate with the compressions or breathing
- D. Validate the client's advanced directive
Correct Answer: C
Rationale: The correct answer is C. The second nurse should assist with compressions or breathing to ensure the patient receives adequate care during CPR. This immediate intervention is crucial in maintaining blood circulation and oxygenation to vital organs. Choice A is incorrect because simply relieving the nurse performing CPR may lead to a delay in essential life-saving measures. Choice B is incorrect as the primary focus should be on providing direct assistance rather than fetching equipment. Choice D is incorrect as validating the client's advanced directive is not the priority in this emergency situation.
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To auscultate for a carotid bruit, where should the nurse place the stethoscope?
- A. Base of the neck on the right side
- B. Above the clavicle
- C. Over the sternum
- D. Over the trachea
Correct Answer: A
Rationale: To auscultate for a carotid bruit, the nurse should place the stethoscope at the base of the neck, near the carotid artery. A carotid bruit is an abnormal sound that indicates turbulent blood flow in the carotid artery, potentially due to arterial narrowing or atherosclerosis. Placing the stethoscope above the clavicle, over the sternum, or over the trachea would not provide the nurse with the optimal location to assess for carotid artery abnormalities.
The nurse is developing an educational program for older clients discharged with new antihypertensive medications. The nurse should ensure that the education materials include which characteristics?
- A. Uses pictures to help illustrate complex ideas
- B. Contains a list with definitions of unfamiliar terms
- C. Uses common words with few syllables
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D, 'All of the above.' When developing educational materials for older clients with new antihypertensive medications, it is essential to include characteristics such as using pictures to illustrate complex ideas, providing a list with definitions of unfamiliar terms, and using common words with few syllables. These features help enhance understanding and medication adherence, especially for older adults who may have challenges with health literacy. Choices A, B, and C collectively address the need for simplicity, visual support, and clarification of terms in educational materials, making them crucial for effective patient education.
A 4-year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first?
- A. Notify the healthcare provider
- B. Readjust the traction
- C. Administer the ordered PRN medication
- D. Reassess the foot in fifteen minutes
Correct Answer: A
Rationale: A pale foot with no pulse suggests a compromised blood supply, indicating a potential vascular emergency. The nurse's immediate priority is to notify the healthcare provider to address the situation promptly. Readjusting the traction, administering PRN medication, or waiting to reassess the foot later could lead to serious complications due to the compromised blood supply, making choices B, C, and D incorrect in this critical situation.
A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?
- A. Allow the client to melt ice chips in the mouth
- B. Provide mints to freshen the breath
- C. Perform frequent oral care with a tooth sponge
- D. Swab the mouth with glycerin swabs
Correct Answer: C
Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure in this scenario. This helps maintain comfort and prevent dryness in clients with nasogastric tubes. Allowing the client to melt ice chips in the mouth may not address oral care needs effectively. Providing mints to freshen the breath is not the priority when the client needs oral care. Swabbing the mouth with glycerin swabs may not be as effective as performing thorough oral care with a tooth sponge.
What might be suggested to a client with fibrocystic breasts in an attempt to help relieve symptoms?
- A. Increase intake of high-calcium foods in your diet
- B. Wear a supportive bra during the day and at night
- C. Take over-the-counter pain relievers
- D. Perform regular breast massage
Correct Answer: B
Rationale: The correct answer is B: 'Wear a supportive bra during the day and at night.' Wearing a supportive bra is essential for individuals with fibrocystic breasts as it helps relieve discomfort by providing necessary support to reduce strain on breast tissue. Option A is incorrect as high-calcium foods are not directly related to symptom relief in fibrocystic breasts. Option C is not the first-line recommendation and may not address the underlying issue. Option D, performing regular breast massage, is not typically recommended and may not provide significant relief for fibrocystic breast symptoms.