Nokea
The client is in ventricular fibrillation. Which interventions should the nurse implement? Select all that apply.
- A. Start cardiopulmonary resuscitation.
- B. Prepare to administer the antidysrhythmic adenosine IVP.
- C. Prepare to defibrillate the client.
- D. Bring the crash cart to the bedside.
- E. Prepare to administer the antidysrhythmic amiodarone IVP.
Correct Answer: A,C,D,E
Rationale: Ventricular fibrillation requires CPR (A), defibrillation (C), crash cart (D), and amiodarone (E). Adenosine (B) is for SVT.
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The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply.
- A. Notify the health-care provider of a weight gain of more than one (1) pound in a week.
- B. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside.
- C. Instruct the client to remove the saltshaker from the dinner table.
- D. Encourage the client to monitor urine output for change in color to become dark.
- E. Discuss the importance of taking the loop diuretic furosemide at bedtime.
Correct Answer: A,B,C
Rationale: Weight gain monitoring (A) detects fluid retention, pulse counting (B) ensures digoxin safety, and removing salt (C) reduces sodium intake. Dark urine (D) is not specific, and furosemide at bedtime (E) causes nocturia, so morning dosing is preferred.
The client with a mechanical valve replacement asks the nurse, 'Why do I have to take antibiotics before getting my teeth cleaned?' Which response by the nurse is most appropriate?
- A. You are at risk of developing an infection in your heart.'
- B. Your teeth will not bleed as much if you have antibiotics.'
- C. This procedure may cause your valve to malfunction.'
- D. Antibiotics will prevent vegetative growth on your valves.'
Correct Answer: A
Rationale: Mechanical valves increase endocarditis risk; antibiotics (A) prevent heart infection during dental procedures. Bleeding (B), valve malfunction (C), and vegetative growth (D) are inaccurate.
The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure?
- A. Perform passive range-of-motion exercises.
- B. Assess the client's neurovascular status.
- C. Keep the client in high Fowler's position.
- D. Assess the gag reflex prior to feeding the client.
Correct Answer: B
Rationale: Post-catheterization, assessing neurovascular status (B) ensures no bleeding or vascular complications. ROM (A) is inappropriate, high Fowler’s (C) is not required, and gag reflex (D) is irrelevant.
The client with infective endocarditis is admitted to the medical department. Which health-care provider’s order should be implemented first?
- A. Administer intravenous antibiotic.
- B. Obtain blood cultures times two (2).
- C. Schedule an echocardiogram.
- D. Encourage bedrest with bathroom privileges.
Correct Answer: B
Rationale: Blood cultures (B) are obtained first in endocarditis to identify the pathogen before antibiotics (A) obscure results. Echocardiogram (C) and bedrest (D) follow.
The client has an implantable cardioverter defibrillator (ICD). Which discharge instructions should the nurse teach the client?
- A. Do not lift or carry more than 23 kg.
- B. Have someone drive the car for the rest of your life.
- C. Carry the cell phone on the opposite side of the ICD.
- D. Avoid using the microwave oven in the home.
Correct Answer: C
Rationale: Carrying the cell phone on the opposite side (C) minimizes electromagnetic interference with the ICD. Lifting limits (A) are typically 10–15 lbs initially, driving (B) is restricted temporarily, and microwaves (D) are safe.