Nokea
Identify this cardiac rhythm strip. Fill in the blank. A. Asystole B. Atrial flutter C. Supraventricular Tachycardia D. Premature Atrial Contractions
- B. Asystole
- C. Atrial flutter
- D. Supraventricular Tachycardia
- E. Premature Atrial Contractions
Correct Answer: A
Rationale: Asystole is a flatline rhythm indicating no electrical activity, assuming the strip matches this description.
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Your client has superior vena cava syndrome. The client's wife asks you what this is. How should you respond to the client's wife? You should explain that superior vena cava syndrome is:
- A. The compression of the renal medulla.
- B. Syncope and dizziness of unknown origin.
- C. Pressure on the vena cava which is a major vein in the body.
- D. Pressure on the vena cava which is the largest artery in the body.
Correct Answer: C
Rationale: Superior vena cava syndrome is caused by compression of the superior vena cava, a major vein, leading to symptoms like swelling and shortness of breath.
The nurse has received the client assignment for the day. Which client should the nurse care for first?
- A. A client with a wound infection who has a temperature of 100.4°F
- B. A client with a deep vein thrombosis who reports bleeding gums when brushing the teeth
- C. A client who had a right arm casted 12 hours ago who is complaining of numbness in the fingers
- D. A client with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 22 beats per minute
Correct Answer: C
Rationale: The client with a cast who experiences numbness in the fingers should be seen first because this could be a symptom of compartment syndrome. Compartment syndrome creates an emergency situation when it does occur. Within 4 to 6 hours after the onset of compartment syndrome, neurovascular and muscle damage are irreversible if treatment is not provided. The limb can become useless in 24 to 48 hours. It would be expected that the client with a wound infection will have an elevation in body temperature. A client on anticoagulant therapy for treatment of a deep vein thrombosis who experiences bleeding gums when brushing teeth should be evaluated but is not the priority. A respiratory rate of 22 breaths per minute in the client with COPD is considered normal.
A 15-month-old child is admitted to the pediatric unit with the diagnosis of pneumonia and is placed in a mass test. Which following toys would be appropriate for this child?
- A. A pull toy.
- B. Storybooks.
- C. Crayons and paper.
- D. Plastic blocks.
Correct Answer: D
Rationale: Plastic blocks are safe and age-appropriate for a 15-month-old, promoting fine motor skills without posing a choking hazard or requiring mobility restricted by a mist tent.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is prescribed budesonide (Pulmicort). The nurse should instruct the client to:
- A. Use the inhaler as needed for shortness of breath.
- B. Rinse the mouth after using the inhaler.
- C. Shake the inhaler before use.
- D. Take two puffs twice daily.
Correct Answer: B
Rationale: Rinsing the mouth after using budesonide prevents oral candidiasis, a common side effect of inhaled corticosteroids.
Allopurinol (Zyloprim) is prescribed for a client who has chronic gout. Which of the following comments indicates that the client understands how to take the allopurinol?
- A. I will take the medication whenever my joints hurt.'
- B. I must take this drug on an empty stomach.'
- C. I should drink plenty of fluids when taking allopurinol.'
- D. I should not take aspirin when taking allopurinol.'
Correct Answer: C
Rationale: Drinking plenty of fluids prevents uric acid crystal formation, enhancing allopurinol's effectiveness in managing gout.