Nokea
The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first?
- A. Administer amiodarone, an antidysrhythmic, IVP.
- B. Prepare to defibrillate the client.
- C. Assess the client's apical pulse and blood pressure.
- D. Start basic cardiopulmonary resuscitation.
Correct Answer: C
Rationale: Ventricular tachycardia requires assessing pulse/BP (C) to determine if it’s pulseless (defibrillation, B) or stable (amiodarone, A). CPR (D) is for pulseless states.
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An adult is admitted with venous thromboembolism. What treatment should the nurse expect during the acute stage?
- A. Application of an elastic stocking
- B. Ambulation three times a day
- C. Passive range of motion exercises to the legs
- D. Use of ice packs to control pain
Correct Answer: A
Rationale: Elastic stockings promote venous return and reduce swelling in the acute stage of venous thromboembolism. Ambulation, passive exercises, or ice packs may increase risk or be less effective.
The nurse counts an adult's apical heart beat at 110 beats per minute. The nurse describes this as:
- A. asystole.
- B. bigeminy.
- C. tachycardia.
- D. bradycardia.
Correct Answer: C
Rationale: Tachycardia in an adult is defined as a heart rate above 100 beats per minute. Asystole is cardiac arrest with no heartbeat. Bigeminy refers to heartbeats occurring in pairs. Bradycardia is a heart rate of 60 beats or less per minute.
The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication?
- A. The client has a BP of 110/70.
- B. The client has an apical pulse of 56.
- C. The client is complaining of a headache.
- D. The client's potassium level is 4.5 mEq/L.
Correct Answer: B
Rationale: Beta blockers slow heart rate; a pulse of 56 (B) may indicate bradycardia, warranting caution. BP 110/70 (A), headache (C), and normal potassium (D) are not contraindications.
The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching?
- A. Do you have a daily bowel movement?'
- B. Do you get yearly chest x-rays (CXRs)?'
- C. Are you sexually active?'
- D. Have you had any weight change?'
Correct Answer: D
Rationale: Weight change (D) may indicate fluid retention or malnutrition, relevant to CAD management. Bowel movements (A), CXRs (B), and sexual activity (C) are less directly related.
The nurse is transcribing the doctor’s orders for a client with congestive heart failure. The order reads 2.5 mg of Lanoxin daily. Which action should the nurse implement?
- A. Discuss the order with the health-care provider.
- B. Take the client’s apical pulse rate before administering.
- C. Check the client’s potassium level before giving the medication.
- D. Determine if a digoxin level has been drawn.
Correct Answer: A
Rationale: Lanoxin (digoxin) 2.5 mg (A) exceeds the safe dose (0.125–0.25 mg daily), requiring HCP clarification. Pulse (B), potassium (C), and digoxin level (D) are routine but secondary to dose error.