Nokea
According to the American Heart Association (2005) guidelines the compression-to-ventilation ratio for one rescuer cardiopulmonary resuscitation is:
- A. 10:01
- B. 20:02
- C. 30:02:00
- D. 40:01:00
Correct Answer: C
Rationale: The 2005 AHA guidelines specify a 30:2 compression-to-ventilation ratio for one-rescuer CPR in adults.
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The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:
- A. Hallucinogenic drugs create both stimulant and depressant effects.
- B. Hallucinogenic drugs induce a state of altered perception.
- C. Hallucinogenic drugs produce severe respiratory depression.
- D. Hallucinogenic drugs induce rapid physical dependence.
Correct Answer: B
Rationale: Continuous observation is needed due to the altered perception caused by hallucinogens, which can lead to unsafe behaviors.
The nurse is caring for a client with suspected endometrial cancer. Which symptom is associated with endometrial cancer?
- A. Frothy vaginal discharge
- B. Thick, white vaginal discharge
- C. Purulent vaginal discharge
- D. Watery vaginal discharge
Correct Answer: D
Rationale: Endometrial cancer often presents with abnormal uterine bleeding, which may manifest as watery or blood-tinged vaginal discharge. Frothy, thick white, or purulent discharges are more indicative of infections or other gynecologic conditions.
An AIDS patient has developed a fungal Fusarium infection. The nurse anticipates the physician will order
- A. lamivudine/zidovudine (Combivir).
- B. famciclovir (Famvir).
- C. ciprofloxacin (Cipro).
- D. voriconazole (Vfend)
Correct Answer: D
Rationale: Voriconazole is an antifungal effective against Fusarium. Combivir (antiretroviral), famciclovir (antiviral), and ciprofloxacin (antibacterial) are not appropriate.
A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be
- A. confused with cold, clammy skin and a pulse of 110.
- B. lethargic with hot, dry skin and rapid, deep respirations.
- C. alert and cooperative with a BP of 130/80 and respirations of 12.
- D. short of breath, with distended neck veins and a bounding pulse of 96.
Correct Answer: A
Rationale: symptoms of hypoglycemia, normal blood sugar 70-110 mg/dL
The nurse administers 6 units of Humalog (lispro) insulin sub-q to a client at 8:30 a.m. The nurse knows to reassess the client and check for a possible hypoglycemic reaction at
- A. 8:45 a.m.
- B. 9:30 a.m.
- C. 11:30 a.m.
- D. 12:00 p.m.
Correct Answer: B
Rationale: Humalog (lispro) is rapid-acting insulin with a peak effect at 1-2 hours. Checking at 9:30 a.m. (1 hour post-administration) aligns with the onset of action to monitor for hypoglycemia.