Nokea
After notifying the provider, the nurse should-----and then-----
- A. prepare the client for cardiac catheterization
- B. request a prescription for an increase in statin medication
- C. administer oxygen at 2 L/min via nasal cannula
- D. request a prescription for a beta-blocker
- E. check a STAT cardiac troponin
- F. administer sublingual nitroglycerin
Correct Answer: C,F
Rationale: Oxygen and nitroglycerin are initial interventions for chest pain relief.
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Which of the following statements should the nurse include in the hand-off report?
- A. The estimated blood loss was 250 milliliters.
- B. The client is a member of the board of directors.
- C. There was a total of 10 sponges used during the procedure.
- D. The client was intubated without complications.
Correct Answer: A
Rationale: The correct answer is A: The estimated blood loss was 250 milliliters. This statement is crucial in a hand-off report as it provides important information about the client's condition post-procedure. It helps alert the receiving nurse to any potential complications or the need for further monitoring.
Statement B is incorrect as the client's position on the board of directors is not relevant to the client's immediate care needs and does not provide useful clinical information. Statement C, the number of sponges used, is also irrelevant to the client's immediate condition and does not impact the client's ongoing care.
Statement D, mentioning intubation without complications, could be important in certain contexts, but in this scenario, information about blood loss is more critical for the receiving nurse to be aware of.
The nurse should first address the client’s-------followed by the client’s-----
- A. safety
- B. abrasions
- C. hygiene
- D. heart rate
- E. pain
- F. BMI
Correct Answer: E,A
Rationale: Addressing pain and safety prioritizes client needs.
Which of the following statements by a client indicates an understanding of the teaching?
- A. I should take antibiotics when I have a virus.
- B. I can visit my nephew who has chickenpox S days after the sores have crusted.
- C. I can clean my cat's litter box during my pregnancy.
- D. I should wish my hands for 10 seconds with hat water after working in the garden.
Correct Answer: B
Rationale: Chickenpox sores crust over before becoming non-contagious.
Which of the following information should the nurse include?
- A. Information Technology will install a firewall to secure client information
- B. You will be asked to change your password once per year.
- C. Documentation of sensitive material is performed by the charge nurse.
- D. You will be given access to the medical records of every client in the facility.
Correct Answer: A
Rationale: Firewalls help protect sensitive client information in electronic health records.
A nurse is assessing a client who is taking haloperidol and is experiencing pseudo parkinsonism. Which of the following findings should the nurse document as a manifestation of pseudo parkinsonism?
- A. Serpentine limb movement
- B. Shuffling gait
- C. Nonreactive pupils
- D. Smacking lips
Correct Answer: B
Rationale: The correct answer is B: Shuffling gait. Pseudo parkinsonism is a common side effect of antipsychotic medications like haloperidol. A shuffling gait is a characteristic manifestation, which includes slow, shuffling, and stiff movements resembling those seen in Parkinson's disease. This occurs due to the blockade of dopamine receptors in the brain.
Choice A, serpentine limb movement, is not a typical manifestation of pseudo parkinsonism. Choice C, nonreactive pupils, is more indicative of a possible neurological issue. Choice D, smacking lips, is a manifestation of tardive dyskinesia, not pseudo parkinsonism.