Nokea
The client is having a cardiac catheterization. During the procedure, the client tells the nurse, 'I'm feeling really hot.' Which response would be best?
- A. You are having an allergic reaction. I will get an order for Benadryl.
- B. That feeling of warmth is normal when the dye is injected.
- C. That feeling of warmth indicates that the clots in the coronary vessels are dissolving.
- D. I will tell your doctor and let him explain to you the reason for the hot feeling that you are experiencing.
Correct Answer: B
Rationale: A warm sensation is a normal response to the injection of contrast dye during cardiac catheterization.
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A client with psychotic depression is receiving haloperidol (Haldol). Which of the following adverse effects is associated with haloperidol?
- A. Akathisia
- B. Cataracts
- C. Diaphoresis
- D. Polyuria
Correct Answer: A
Rationale: Akathisia, a movement disorder characterized by restlessness, is a common extrapyramidal side effect of haloperidol.
A client is scheduled for a colposcopy. The nurse assists the client into which position?
- A. Sim's position
- B. supine position, with the head of the bed elevated 15 degrees
- C. left-side-lying position, knees to chest
- D. lithotomy position
Correct Answer: D
Rationale: Colposcopy requires the lithotomy position to provide access to the cervix for examination.
A client is admitted with suspected acute pancreatitis. Which lab finding confirms the diagnosis?
- A. Blood glucose of 260 mg/dL
- B. White cell count of 21,000 cu/mm
- C. Platelet count of 250,000 cu/mm
- D. Serum amylase level of 600 units/dL
Correct Answer: D
Rationale: Elevated serum amylase levels, particularly above 3 times the normal range, confirm acute pancreatitis due to pancreatic enzyme release.
Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
- A. Record the pulse rate and administer the medication
- B. Administer the medication and monitor the heart rate
- C. Withhold the medication and notify the doctor
- D. Withhold the medication until the heart rate increases
Correct Answer: C
Rationale: A pulse rate below 60 bpm is a contraindication for digoxin administration due to the risk of worsening bradycardia, so the nurse should withhold the dose and notify the physician.
The nurse is caring for a client with scalding burns across the face, neck, upper half of the anterior chest, and entire right arm. Using the rule of nines, estimate the percentage of body burned.
- A. 18%
- B. 23%
- C. 32%
- D. 36%
Correct Answer: B
Rationale: Rule of nines: face/neck (4.5% head anterior), upper half anterior chest (4.5% anterior torso/2 = 2.25%), right arm (9%) = 4.5 + 2.25 + 9 = 23%.