An adult is scheduled for a cardioversion next week. What should the nurse plan to include when teaching the client about the procedure?
- A. The client should be NPO for eight hours before the procedure.
- B. The client will be awake during the procedure.
- C. The procedure will probably need to be repeated every month for at least six months.
- D. The procedure is usually done for life-threatening dysrhythmias such as ventricular fibrillation.
Correct Answer: A
Rationale: Cardioversion requires sedation, so the client must be NPO for 8 hours to prevent aspiration. The client is sedated, not awake, it's not typically repeated monthly, and it's used for atrial arrhythmias, not ventricular fibrillation.
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The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about energy conservation. Which of the following strategies should the nurse recommend?
- A. Perform all activities in the morning when energy is highest.
- B. Use a shower chair when bathing.
- C. Avoid using a pursed-lip breathing technique.
- D. Walk quickly to complete tasks efficiently.
Correct Answer: B
Rationale: Using a shower chair conserves energy by reducing exertion during bathing, a taxing activity for COPD patients. Morning activity (A) may not suit all, pursed-lip breathing (C) aids respiration, and quick walking (D) increases oxygen demand.
While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?
- A. Jaundice evident at 26 hours
- B. Hematocrit of 55%
- C. Serum bilirubin of 12 mg
- D. Positive Coombs' test
Correct Answer: C
Rationale: The elevated bilirubin is in the range that requires immediate intervention, such as phototherapy. At a serum bilirubin of 12 mg, the neonate is at risk for the development of kernicterus, or bilirubin encephalopathy. The provider determines the therapy appropriate after reviewing all laboratory findings.
A client has been on antibiotics for 72 hours for cystitis.
Which report from the client requires priority attention by the nurse?
- A. Dysuria
- B. Body malaise
- C. Rashes all over the body and slight breathing problems.
- D. Poor appetite.
Correct Answer: C
Rationale: Rashes and breathing problems are signs of a delayed allergic reaction to antibiotics, requiring urgent attention.
A nurse is preparing to administer an intramuscular injection. Which of the following sites is most appropriate for an adult patient?
- A. Deltoid
- B. Vastus lateralis
- C. Dorsogluteal
- D. Ventrogluteal sites
Correct Answer: D
Rationale: The ventrogluteal site is safest for IM injections in adults, minimizing nerve or vessel damage. Deltoid and vastus lateralis are alternatives but less preferred, and dorsogluteal is avoided due to sciatic nerve risk.
An adult is to go to surgery this morning. When the nurse goes to medicate the client, she notes that she has a ring with several shiny stones in it on her left ring finger. There are no relatives present. What is the best nursing action?
- A. Tape the ring before medicating the client.
- B. Ask the client to put the ring in the bedside drawer.
- C. Label the ring and place it in an envelope in the hospital safe.
- D. Have the client sign a waiver regarding responsibility for the ring.
Correct Answer: C
Rationale: Securing valuables in the hospital safe protects the ring during surgery, adhering to safety protocols. Taping, bedside storage, or waivers risk loss.
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