Nokea
Prior to the patient being given medication, he becomes hypotensive, mottled, and cold. His heart rate is 240. The next therapeutic step should be
- A. digoxin
- B. synchronized DC cardioversion
- C. lidocaine
- D. defibrillation
Correct Answer: B
Rationale: Synchronized DC cardioversion is indicated for unstable tachycardia unresponsive to pharmacological agents.
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What information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)?
- A. Sleep without pillows at night to maintain neck alignment.
- B. Adjust food intake to three full meals per day and no snacks.
- C. Minimize symptoms by wearing loose, comfortable clothing
- D. Avoid participation in any aerobic exercise programs
Correct Answer: C
Rationale: Loose clothing reduces pressure on the abdomen, which can help minimize GERD symptoms.
A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse?
- A. Irregular apical pulse
- B. Purple marks on the skin of the abdomen
- C. Quarter size blood spot on dressing
- D. Pitting ankle edema
Correct Answer: A
Rationale: An irregular apical pulse could indicate cardiac complications, which are a risk in clients with Cushing's syndrome due to fluid and electrolyte imbalances.
A woman who works as a data entry clerk is concerned as to how recent diagnosis of Raynaud's syndrome is going to affect her job performance. Which instruction should the nurse provide this client?
- A. Use a space heater to keep the workspace warm
- B. Keep hands elevated above the heart to prevent swelling.
- C. Wear tight gloves during work to avoid temperature fluctuations.
- D. Take frequent breaks to improve circulation in the hands.
Correct Answer: A
Rationale: Keeping the hands warm helps prevent vasospasms, which are characteristic of Raynaud's syndrome.
Evidence of increased pulmonary flow is associated with:
- A. Coarctation of the aorta
- B. Fallot's tetralogy
- C. Pneumocystis infection
- D. Ventricular septal defect
Correct Answer: D
Rationale: A ventricular septal defect (VSD) leads to increased pulmonary blood flow due to left-to-right shunting, resulting in pulmonary congestion.
A child with rheumatic fever is being admitted to the pediatric floor. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever?
- A. “Has your child complained of back pain?â€
- B. “Has your child complained of headaches?â€
- C. “Has your child had any nausea or vomiting?â€
- D. “Did your child have a sore throat or fever within the last 2 months?â€
Correct Answer: D
Rationale: A history of sore throat or fever within the last 2 months is significant as rheumatic fever often follows a streptococcal infection such as strep throat.