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Based on the interpretation of this strip, what action should be implemented first?
- A. Call a code.
- B. Start CPR.
- C. Administer IV fluids.
- D. Apply oxygen.
Correct Answer: A
Rationale: The correct answer is A: 'Call a code.' In the context of ventricular fibrillation (V-Fib), immediate defibrillation is crucial. Calling a code is the first step to activating the emergency response team, including individuals trained to provide defibrillation. Starting CPR (Choice B) may be necessary but should follow defibrillation. Administering IV fluids (Choice C) and applying oxygen (Choice D) are important interventions in cardiac arrest cases, but in V-Fib, the priority is defibrillation to restore normal heart rhythm.
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What are the clinical manifestations of otitis media?
- A. Earache, wheezing, vomiting
- B. Coughing, rhinorrhea, headache
- C. Fever, irritability, pulling on ear
- D. Wheezing, cough, drainage in ear canal
Correct Answer: C
Rationale: The correct answer is C: Fever, irritability, pulling on the ear. Clinical manifestations of otitis media commonly include fever, irritability, and children may show signs of pulling or rubbing their ears. Choices A, B, and D are incorrect. Choice A includes wheezing and vomiting, which are not typical symptoms of otitis media. Choice B includes coughing, rhinorrhea, and headache, which are more commonly associated with upper respiratory infections rather than otitis media. Choice D includes wheezing, cough, and drainage in the ear canal, which are not typical clinical manifestations of otitis media.
The nurse is caring for a child who has been diagnosed with attention deficit hyperactivity disorder (ADHD). What is the most important intervention for the nurse?
- A. Help the child enroll in a special education class.
- B. Allay any feelings of guilt the parents may have.
- C. Explain to the parents that medications are lifelong.
- D. Teach the parents how to set limits.
Correct Answer: B
Rationale: The most important intervention for the nurse in caring for a child with ADHD is to allay any feelings of guilt the parents may have. Parents of children with ADHD often experience guilt or self-blame, thinking they are responsible for their child's condition. By addressing and alleviating these feelings, the nurse can support the parents in a crucial way. Choice A is not the most important intervention because enrolling the child in a special education class might be a consideration but does not address the emotional needs of the parents. Choice C is incorrect because stating that medications are lifelong may cause unnecessary distress to the parents. Choice D is also not the most important intervention as setting limits is important but not as critical as addressing parental guilt and emotions.
The settings on a client's synchronized intermittent mandatory ventilation (SIMV) are respiratory rate 12 breaths/minute, tidal volume at 600 mL, FiO2 35%, and positive end-expiratory pressure (PEEP) 5 cm H2O. Which assessment finding necessitates immediate intervention by the nurse?
- A. Bilateral crackles in the lung bases.
- B. Low-pressure indicator alarm.
- C. Oxygen saturation of 91%.
- D. Respiratory rate of 18 breaths/minute.
Correct Answer: B
Rationale: A low-pressure alarm may indicate a disconnection or leak in the system, which needs immediate intervention. Bilateral crackles in the lung bases may indicate fluid overload but do not require immediate intervention in this case. An oxygen saturation of 91% is concerning but not as urgent as a potential equipment issue. A respiratory rate of 18 breaths/minute is higher than the set rate but may not necessitate immediate intervention unless accompanied by other distress symptoms.
An older adult with chronic obstructive pulmonary disease (COPD) was recently admitted to the hospital with heart failure (HF). Which actions should the nurse take in providing care? (Select all that apply)
- A. Monitor electrolyte levels.
- B. Maintain pulse oximetry.
- C. Provide assistance with mobility.
- D. All of the Above
Correct Answer: D
Rationale: In a patient with COPD and HF, monitoring electrolyte levels is essential due to potential imbalances caused by medications or fluid shifts. Maintaining pulse oximetry is crucial to assess oxygenation status in COPD and HF. Providing assistance with mobility helps prevent deconditioning and complications. Therefore, all the actions mentioned are necessary for comprehensive care in this scenario, making option D the correct answer. Choices A, B, and C are all important aspects of managing COPD and HF, ensuring holistic and effective care.
The healthcare provider is assessing a client with a chest tube. Which finding indicates that the chest tube is functioning properly?
- A. Continuous bubbling in the water seal chamber
- B. Tidaling in the water seal chamber
- C. Absence of drainage in the collection chamber
- D. Fluid level in the suction control chamber is below the prescribed level
Correct Answer: B
Rationale: Tidaling in the water seal chamber indicates proper chest tube function. Tidaling refers to the rise and fall of fluid in the water seal with inhalation and exhalation, demonstrating the patency of the system. Continuous bubbling (Choice A) in the water seal chamber indicates an air leak. Absence of drainage in the collection chamber (Choice C) is not a desired finding as it suggests no drainage is occurring. A fluid level below the prescribed level in the suction control chamber (Choice D) may indicate inadequate suction.