Nokea
After the client has been successfully resuscitated by the nurse, which body position is most correct while awaiting transfer to the emergency department?
- A. Supine with the head elevated
- B. On the side upper knee flexed
- C. Prone with the head lowered
- D. Flat with the knees extended
Correct Answer: D
Rationale: Flat with knees extended ensures airway patency and circulation stability post-resuscitation.
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Which intervention should the nurse implement with the client diagnosed with dilated cardiomyopathy?
- A. Keep the client in the supine position with the legs elevated.
- B. Discuss a heart transplant, which is the definitive treatment.
- C. Prepare the client for coronary artery bypass graft.
- D. Teach the client to take a calcium channel blocker in the morning.
Correct Answer: B
Rationale: Dilated cardiomyopathy may require heart transplant (B) as definitive treatment in severe cases. Supine position (A) increases preload, CABG (C) is for CAD, and calcium channel blockers (D) are not first-line.
Which modification used by the nurse is most appropriate when taking the blood pressure of a client who weighs 250 pounds?
- A. The nurse takes the blood pressure on the client's thigh.
- B. The nurse has the client lie down during the assessment.
- C. The nurse pumps the manometer up to 250 mm Hg.
- D. The nurse uses an extra-large blood pressure cuff.
Correct Answer: D
Rationale: An extra-large blood pressure cuff is appropriate for clients with larger arm circumferences, such as those who are obese, to ensure accurate readings. Using the thigh, lying down, or over-inflating the cuff does not address the need for proper cuff size.
Before administering the digoxin (Lanoxin) to the client, what nursing assessment is essential?
- A. The client's heart rate
- B. The client's blood pressure
- C. The client's heart sounds
- D. The client's breath sounds
Correct Answer: A
Rationale: Check heart rate; withhold digoxin if <60 bpm to prevent toxicity.
The telemetry nurse is unable to read the telemetry monitor at the nurse’s station. Which intervention should the telemetry nurse implement first?
- A. Go to the client's room to check the client.
- B. Instruct the primary nurse to assess the client.
- C. Contact the client on the client call system.
- D. Request the nursing assistant to take the crash cart to the client's room.
Correct Answer: A
Rationale: An unreadable monitor (A) requires direct client assessment to ensure safety. Instructing another nurse (B), calling (C), or crash cart (D) are premature without assessment.
The nurse informs the client that the correct way to administer nitroglycerin is to place one tablet where?
- A. The nurse is the first and check
- B. At the back of the throat
- C. Under the tongue
- D. Between the teeth
Correct Answer: C
Rationale: Sublingual nitroglycerin is placed under the tongue for rapid absorption into the bloodstream to relieve angina.