Nokea
A nurse is teaching an ACLS class and is discussing heart rhythms and treatment. Which of the following rhythms would indicate the need for defibrillation?
- A. Atrial fibrillation
- B. Supraventricular tachycardia
- C. Asystole
- D. Ventricular fibrillation
Correct Answer: D
Rationale: Ventricular fibrillation is a life-threatening rhythm requiring immediate defibrillation.
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A nurse is assessing a client who has left-sided heart failure. Which of the following clinical manifestations will the nurse expect?
- A. Lower extremity edema
- B. Crackles in lung bases
- C. Jugular vein distention
- D. Ascites
Correct Answer: B
Rationale: Crackles indicate pulmonary congestion characteristic of left-sided heart failure.
A client is being admitted to the emergency department with a possible dissecting abdominal aortic aneurysm. Which of the following clinical manifestations are not signs and symptoms of hypovolemic shock?
- A. Nausea and faintness
- B. Neurologic deficits and apprehension
- C. Hypertension and tachypnea
- D. Diaphoresis and oliguria
Correct Answer: C
Rationale: Hypertension is not typical in hypovolemic shock (hypotension is expected).
A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?
- A. Sodium level
- B. Intake and output
- C. Daily weight
- D. Tissue turgor
Correct Answer: C
Rationale: Daily weight is the most reliable measure of fluid retention as 1 kg weight gain equals approximately 1 liter fluid retention.
A nurse is preparing to administer a 2 mg IV bolus of morphine sulfate. Morphine sulfate is available in a concentration of 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.2
Rationale: Calculation: 2 mg ÷ 10 mg/mL = 0.2 mL
The nurse is caring for a client with cirrhosis and portal hypertension. Which statement by the client is cause for the greatest concern?
- A. I have a tight sensation in my lower leg when I forget to put my feet up.
- B. I can't button my pants anymore because my belly is so swollen.
- C. I'm very constipated and have been straining during bowel movements.
- D. When I sleep, I have to sit in a recliner so that I can breathe more easily.
Correct Answer: B
Rationale: This indicates new or worsening ascites, a serious complication of portal hypertension requiring evaluation.