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After a client with an Automated Internal Cardiac Defibrillator (AICD) is successfully defibrillated for Ventricular Fibrillation (VF), what should the nurse do next?
- A. Go to the client to assess for signs and symptoms of decreased cardiac output.
- B. Call the physician to inform them of the VF episode for medication adjustments.
- C. Call the 'on-call' person in the cath lab to re-charge the ICD in case of a recurrence.
- D. Document the incident on the code report form and follow up regularly.
Correct Answer: A
Rationale: After a client is successfully defibrillated, the immediate priority is to assess the client for signs and symptoms of decreased cardiac output, such as altered level of consciousness, chest pain, shortness of breath, or hypotension. This assessment is crucial to determine the effectiveness of the defibrillation and the client's current hemodynamic status. Calling the physician for medication adjustments without assessing the client first could delay essential interventions. Contacting the 'on-call' person in the cath lab to re-charge the ICD is not the initial action needed after successful defibrillation. Documenting the incident is important but should not take precedence over assessing the client's immediate condition.
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After discontinuing a peripherally inserted central line (PICC), what information is most important for the nurse to record?
- A. How the client tolerated the procedure.
- B. The length and intactness of the central line catheter.
- C. The amount of fluid left in the IV solution container.
- D. That a dressing was applied to the insertion site.
Correct Answer: B
Rationale: The most important information for the nurse to record after discontinuing a peripherally inserted central line (PICC) is the length and intactness of the central line catheter. This is crucial for assessing any potential complications or safety issues post-removal. Choices A, C, and D are not as critical as ensuring the condition of the central line catheter. While noting the client's tolerance of the procedure is relevant for their care assessment, evaluating the central line's integrity takes precedence in this scenario.
A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse about the reason for having two chest tubes. The nurse's response is based on the knowledge that the upper chest tube is placed to:
- A. Remove air from the pleural space
- B. Create access for irrigating the chest cavity
- C. Evacuate secretions from the bronchioles and alveoli
- D. Drain blood and fluid from the pleural space
Correct Answer: A
Rationale: The correct answer is 'Remove air from the pleural space.' When a client has two chest tubes in place post-thoracotomy, the upper chest tube is typically positioned to remove air from the pleural space. Air rises, so placing the tube at the top allows for efficient removal of air that has accumulated in the pleural cavity. Choice B, creating access for irrigating the chest cavity, is incorrect as chest tubes are not primarily used for irrigation. Choice C, evacuating secretions from the bronchioles and alveoli, is incorrect as chest tubes are not designed for this purpose. Choice D, draining blood and fluid from the pleural space, is also incorrect as the upper chest tube in this scenario is specifically for removing air, not blood or fluid.
A client has been receiving cyanocobalamin (B12) injections for the past 6 weeks. Which laboratory finding indicates that the medication is having the desired effect?
- A. Neutrophil count of 60%
- B. Basophil count of 0.5%
- C. Monocyte count of 2%
- D. Reticulocyte count of 1%
Correct Answer: D
Rationale: Cyanocobalamin is a B12 medication used for pernicious anemia. A reticulocyte count of 1% indicates the desired effect of the medication, as reticulocytes are immature red blood cells that increase in response to B12 therapy, improving anemia. Neutrophils, basophils, and monocytes are white blood cells and are not directly influenced by B12 injections, making them incorrect choices.
The client has jaundice, elevated liver enzymes, and an elevated serum bilirubin. What color urine does the nurse expect to find?
- A. Pink-tinged
- B. Straw-colored
- C. Clear
- D. Dark amber
Correct Answer: D
Rationale: The correct answer is dark amber. In jaundice, the elevated bilirubin levels are excreted in the urine, giving it a dark amber color. Choices A, B, and C are incorrect because in jaundice, the urine typically appears dark amber due to the presence of elevated bilirubin, not pink-tinged, straw-colored, or clear.
What is the most common cause of acute renal failure?
- A. Shock
- B. Nephrotoxic drugs
- C. Enlarged prostate
- D. Diabetes
Correct Answer: A
Rationale: The most common cause of acute renal failure is shock. In cases of shock, such as hypovolemic shock where there is low blood volume, the kidneys receive inadequate blood flow leading to acute renal failure. This can result in the kidneys starting to die within 20 minutes of low pressure. While nephrotoxic drugs can also cause acute renal failure, shock is more commonly associated with this condition. An enlarged prostate can lead to urinary retention but is not the most common cause of acute renal failure. Diabetes, on the other hand, can cause chronic kidney disease over time but is not typically the primary cause of acute renal failure.