Nokea
The client is receiving thrombolytic therapy for a diagnosed myocardial infarction (MI). Which assessment data indicate the therapy is successful?
- A. The client's ST segment is becoming more depressed.
- B. The client is exhibiting reperfusion dysrhythmias.
- C. The client's cardiac isoenzyme CK-MB is not elevated.
- D. The D-dimer is negative at two (2) hours post-MI.
Correct Answer: B
Rationale: Reperfusion dysrhythmias (e.g., PVCs) indicate restored coronary flow, a sign of thrombolytic success. ST depression, normal CK-MB, or D-dimer are not specific.
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A nurse is assigned to perform well-child assessments at a day care center. A staff member interrupts the examinations to ask for assistance. They find a crying 3 year-old child on the floor with mouth wide open and gums bleeding. Two unlabeled open bottles lie nearby. The nurse's first action should be
- A. call the poison control center, then 911
- B. administer syrup of Ipecac to induce vomiting
- C. give the child milk to coat her stomach
- D. ask the staff about the contents of the bottles
Correct Answer: D
Rationale: ask the staff about the contents of the bottles. The nurse needs to assess what the child ingested before determining the next action. Once the substance is identified, the poison control center and emergency response team should be called.
The client is experiencing supraventricular tachycardia (SVT). Which antidysrhythmic medication should the nurse prepare to administer?
- A. Atropine.
- B. Amiodarone.
- C. Adenosine.
- D. Dobutamine.
Correct Answer: C
Rationale: Adenosine is first-line for SVT, rapidly terminating the arrhythmia, per ACLS guidelines. Other drugs are used for different rhythms.
The nurse is administering the following 1800 medications. Which medication should the nurse question before administering?
- A. The sliding-scale insulin to the client who has just been released to have the evening meal.
- B. The antibiotic to the client who is one (1) day postoperative exploratory abdominal surgery.
- C. Metformin (Glucophage), a biguanide, to the client having a CT scan with contrast dye in the morning.
- D. Protonix, a proton pump inhibitor, to the client diagnosed with peptic ulcer disease.
Correct Answer: C
Rationale: Metformin must be held before contrast dye due to lactic acidosis risk if renal function is impaired; other medications are appropriate.
An adult client is seen in the clinic, and sulfisoxazole (Gantrisin) is prescribed. Which information is most appropriate for the nurse to include in the teaching?
- A. Limit your fluid intake to four glasses a day.
- B. If it upsets your stomach, try taking it with an antacid.
- C. Avoid going out in the sun while taking this drug.
- D. Take the tablets with orange juice or milk.
Correct Answer: C
Rationale: Sulfisoxazole causes photosensitivity; avoiding sun exposure is critical to prevent skin reactions.
A client is receiving digitalis. The nurse should instruct the client to report which of the following side effects?
- A. Nausea, vomiting, fatigue
- B. Rash, dyspnea, edema
- C. Polyuria, thirst, dry skin
Correct Answer: A
Rationale: Nausea, vomiting, fatigue. Side effects of digitalis toxicity include fatigue, nausea, vomiting, anorexia, and bradycardia. Digitalis inhibits the sodium potassium ATPase, which makes more calcium available for contractile proteins, resulting in increased cardiac output.