Nokea
The ECG in left ventricular hypertrophy and shows a superior QRS axis (between -90' and 0')
- A. tricuspid atresia
- B. Ebstein anomaly
- C. pulmonary atresia
- D. tetralogy of Fallot
Correct Answer: D
Rationale: Left ventricular hypertrophy with a superior QRS axis is characteristic of tetralogy of Fallot.
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A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?
- A. Teach the client techniques for performing intermittent catheterization
- B. Increase the client's fluid intake to promote frequent urination.
- C. Suggest the use of incontinence pads for comfort
- D. Administer anticholinergic medications to enhance bladder function.
Correct Answer: A
Rationale: Intermittent catheterization helps manage urinary retention and prevents complications like urinary tract infections.
The nurse is caring for a child with cystic fibrosis. Which intervention is most important when the child is hospitalized with a respiratory infection?
- A. Administer prescribed antibiotics as soon as possible.
- B. Increase fluid intake to help thin mucus.
- C. Provide respiratory treatments and postural drainage.
- D. Encourage high-calorie, high-protein meals.
Correct Answer: C
Rationale: Respiratory treatments and postural drainage are critical to help clear mucus from the lungs in children with cystic fibrosis, especially during respiratory infections.
A young female client with seven children is having frequent morning headaches, dizziness, and blurred vision. Her blood pressure (BP) is 168/104 mmHg. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV medication, which intervention is most important for the nurse to implement?
- A. Measure urine output hourly to assess for rental perfusion
- B. Request a prescription for pain medication
- C. Use an automated BP machine to monitor for hypotension
- D. Provide a quiet environment with low lighting
Correct Answer: C
Rationale: Monitoring blood pressure is crucial after administering an antihypertensive to ensure the client does not become hypotensive.
Drugs to be avoided in renal failure include:
- A. Allopurinol
- B. Digoxin
- C. Ceftazidime
- D. Acyclovir
Correct Answer: B
Rationale: Digoxin is avoided in renal failure due to its narrow therapeutic index and renal excretion, which can lead to toxicity.
After a transurethral resection of the prostate (TURP), a client has bloody urine output with large clots. The nurse implements the postoperative prescription to irrigate the indwelling catheter PRN to maintain the catheter's patency. Which action should the nurse implement?
- A. Clamp the catheter for 30 minutes prior to irrigating with saline
- B. Manually irrigate the catheter with sterile saline as prescribed
- C. Increase the client's oral fluid intake to flush out clots naturally
- D. Remove the catheter and notify the healthcare provider immediately
Correct Answer: A
Rationale: Clamping the catheter before irrigation prevents sudden fluid shifts and ensures that irrigation is performed effectively.