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The hospital nurse administers CPR to an adult male who is found unconscious, has no pulse, and is not breathing. What is the ratio of chest compressions to respirations for one-person rescue?
- A. Fifteen chest compressions to one breath
- B. Fifteen chest compressions to two breaths
- C. Thirty chest compressions to two breaths
- D. Thirty chest compressions to two breaths
Correct Answer: C
Rationale: Current CPR guidelines recommend 30 chest compressions to 2 breaths for one-person adult resuscitation, optimizing circulation and oxygenation.
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The nurse is caring for an adult male who is receiving haloperidol (Haldol). Which complaint by the client is of most concern to the nurse and should be immediately reported?
- A. I have gained so much weight in the last few months.
- B. I am having trouble getting an erection.
- C. My legs are cramping and I feel like I need to walk all the time.
- D. It's really embarrassing. I'm drooling a lot.
Correct Answer: C
Rationale: Leg cramping and restlessness suggest akathisia, a serious extrapyramidal side effect of haloperidol, requiring immediate reporting.
Laboratory reference ranges
BUN
10-20 mg/dL
(3.6-7.1 mmol/L)
An 80-year-old client is receiving amikacin, an aminoglycoside antibiotic, IVPB every 12 hours. Which of the following data obtained
by the practical nurse is most important to report to the registered nurse before the client receives the next dose?
- A. client reports tinnitus
- B. Blood pressure 104/60 mm Hg
- C. urine output of 400 mL since last dose
Correct Answer: A
Rationale: Tinnitus may indicate ototoxicity, requiring immediate reporting. Low BP and urine output are less urgent without context of medication.
A Spanish-speaking client is admitted for a small bowel obstruction. The surgeon explains to the client's child, who speaks both Spanish and English, that an exploratory laparotomy is needed to determine the cause of the obstruction and that possible causes include intestinal adhesions and ovarian or colon cancer. The surgeon asks the child to translate this information for the client and assist with translating the consent form. Which action by the nurse would be most appropriate?
- A. Act as a witness for the informed consent process
- B. Reinforce information about what the client can expect
- C. Report the surgeon to the ethics board for using an inappropriate consent process
- D. Talk to the surgeon privately about using a trained Spanish-language medical interpreter
Correct Answer: D
Rationale: Using a trained interpreter ensures accurate, unbiased communication. Witnessing or reinforcing perpetuates the error, and reporting is premature.
A 7 year-old child is hospitalized following a major burn to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse informs the child and family that the most important reason for this diet is to
- A. Promote healing and strengthen the immune system
- B. Provide a well balanced nutritional intake
- C. Stimulate increased peristalsis absorption
- D. Spare protein catabolism to meet metabolic needs
Correct Answer: D
Rationale: Spare protein catabolism to meet metabolic needs. A high-carbohydrate diet prevents protein breakdown for energy, allowing proteins to restore tissue.
The nurse is caring for a client receiving Theodur (theophylline). Side effects associated with bronchodilators include:
- A. Irritability, rapid pulse, and palpitations
- B. Slow pulse, increased appetite, and sweating
- C. Anxiety, nausea, and increased blood pressure
- D. Drowsiness, vomiting, and decreased blood sugar
Correct Answer: A
Rationale: Theophylline can cause irritability, rapid pulse, and palpitations due to its stimulant effects. Slow pulse , drowsiness , or decreased blood sugar are not typical.