Nokea
The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. Which is the priority nursing action?
- A. Activate the rapid response team.
- B. Assess the client's orientation and vital signs.
- C. Administer a bolus of lidocaine.
- D. Notify the physician.
Correct Answer: B
Rationale: PVCs every other beat (bigeminy) may indicate serious irritability. Assessing orientation and vital signs first determines the client's stability, guiding further actions.
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A client is newly diagnosed with cancer and is beginning a treatment plan. Which of the following nursing interventions will be most effective in helping the client cope?
- A. Assume decision making for the client.
- B. Encourage the client's compliance with all treatment regimens.
- C. Inform the client of all possible adverse treatment effects.
- D. Identify available resources.
Correct Answer: D
Rationale: Identifying available resources (e.g., support groups, counseling) empowers the client to cope with the emotional and practical challenges of a new cancer diagnosis.
What action should this nurse take to avoid spreading nosocomial infections?
- A. Remove the face mask.
- B. Remove the hair covering.
- C. Wash her hands before tying the strings on the mask.
- D. Tie the dangling strings of the mask around her neck.
Correct Answer: C
Rationale: Hand hygiene is critical to prevent nosocomial infections. Washing hands before handling the mask ensures the nurse does not contaminate it or transfer pathogens. Removing protective gear or tying strings improperly could increase infection risk.
The nurse should instruct a client who has been diagnosed with vasospastic disorder (Raynaud's phenomenon) to:
- A. Immerse her hands in cold water during an episode
- B. Wear light garments when the temperature gets below 50°F (10°C)
- C. Wear gloves when handling ice or frozen foods
- D. Live in a cold climate
Correct Answer: C
Rationale: Wearing gloves when handling ice or frozen foods prevents cold-induced vasospasm in Raynaud's. Cold water worsens symptoms, light garments are insufficient in cold temperatures, and living in a cold climate increases episode frequency.
A client has had hoarseness for more than 2 weeks. The nurse should:
- A. Refer to a health care provider for a prescription for an antibiotic.
- B. Instruct the client to gargle with salt water at home.
- C. Assess the client for dysphagia.
- D. Instruct the client to take a throat analgesic.
Correct Answer: C
Rationale: Persistent hoarseness may indicate laryngeal pathology, including cancer; assessing for dysphagia (difficulty swallowing) helps evaluate severity and urgency. Antibiotics are inappropriate without a bacterial diagnosis. Gargling or analgesics may mask symptoms without addressing the cause.
Which of the following nursing interventions is appropriate for a client with an increased intracranial pressure (ICP) of 20 mm Hg?
- A. Give the client a warming blanket.
- B. Administer low-dose barbiturates.
- C. Encourage the client to hyperventilate.
- D. Restrict fluids.
Correct Answer: B
Rationale: Low-dose barbiturates can reduce cerebral metabolism and ICP, making them appropriate in some cases under medical supervision. Warming blankets increase metabolic demand, hyperventilation is no longer routinely recommended due to risks of cerebral vasoconstriction, and fluid restriction is not standard for ICP management unless specifically indicated.