Nokea
Identify this cardiac rhythm strip. Fill in the blank. A. Torsades de Pointes B. Accelerated Idioventricular Arrhythmia C. First Degree Atrioventricular Heart Block D. Supraventricular tachycardia
- B. Torsades de Pointes
- C. Accelerated Idioventricular Arrhythmia
- D. First Degree Atrioventricular Heart Block
- E. Supraventricular tachycardia
Correct Answer: C
Rationale: First Degree AV Block is characterized by a prolonged PR interval, assuming the strip shows this pattern.
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A client has a viral (coxsackie B) or trypanosomal (parasite) infection. The nurse should further assess the client for:
- A. Myocarditis.
- B. Myocardial infarction.
- C. Renal failure.
- D. Liver failure.
Correct Answer: A
Rationale: Coxsackie B and trypanosomal infections are associated with myocarditis, an inflammation of the heart muscle, which requires further assessment.
A client with a history of asthma is prescribed albuterol (Proventil). The nurse should instruct the client to:
- A. Use the inhaler daily to prevent attacks.
- B. Rinse the mouth after each use.
- C. Use the inhaler during an acute attack.
- D. Stop the inhaler if heart palpitations occur.
Correct Answer: C
Rationale: Albuterol is a rescue inhaler used during acute asthma attacks to relieve bronchospasm.
Your pregnant client has a new order for a medication. What principle should you apply to this new medication?
- A. The fact that drugs classified as categories C, D and X are contraindicated for women who are pregnant.
- B. The fact that drugs classified as categories A, B and C are contraindicated for women who are pregnant.
- C. The fact that drugs classified as categories C, D and E are contraindicated for women who are pregnant.
- D. The fact that drugs classified as categories C, D and Z are contraindicated for women who are pregnant.
Correct Answer: A
Rationale: Drugs in FDA pregnancy categories C, D, and X carry risks (potential harm, known harm, or absolute contraindication, respectively) and are generally contraindicated in pregnancy unless benefits outweigh risks.
As the nurse in an ambulatory care area, you see a new client enter with a cane that appears too short for the client. What should you do?
- A. Place the client in a wheelchair to protect their safety in the clinic.
- B. Remove the cane from the client to protect their safety.
- C. Teach the client about the proper length of a cane.
- D. Have the client use a wheelchair rather than the cane.
Correct Answer: C
Rationale: Teaching the client about proper cane length (handle at wrist level when arm is relaxed) promotes safe and effective mobility.
The nurse is informed that a newborn infant with Apgar scores of 1 and 4 will be brought to the nursery. The nurse determines that which intervention is the priority?
- A. Connecting the resuscitation bag to oxygen
- B. Turning on the apnea and cardiorespiratory monitor
- C. Preparing for the insertion of an intravenous (IV) line with D5W
- D. Setting up the radiant warmer control temperature at 36.5°C (97.6°F)
Correct Answer: A
Rationale: The top priority action for a newborn infant with low Apgar scores is maintaining a patent airway, which would involve preparing respiratory resuscitation equipment. Although the remaining options are also important, they are of lower priority. The newborn infant's cardiopulmonary status would be monitored by a cardiorespiratory monitoring device. Setting up an IV with D5W would provide circulatory support. The radiant warmer will provide an external heat source, which is necessary to prevent further respiratory distress.