Nokea
The nurse assisting in the care of a client who is to be cardioverted should plan to set the monophasic defibrillator to which starting energy levels range, depending on the specific primary health care provider prescription?
- A. 50 to 100 joules
- B. 200 to 250 joules
- C. 250 to 300 joules
- D. 350 to 400 joules
Correct Answer: A
Rationale: Cardioversion is synchronized countershock to convert an undesirable rhythm to a stable rhythm. Cardioversion is usually started at 50 to 100 joules. When a client is cardioverted, the defibrillator is charged to the energy level prescribed by the primary health care provider, and the remaining options identify energy levels that are too high for cardioversion.
You may also like to solve these questions
A client reporting abdominal pain has a diagnosis of acute abdominal syndrome but the cause has not been determined. Which prescription should the nurse question at this time?
- A. Clear liquid diet only
- B. Insertion of a nasogastric tube
- C. Administration of an analgesic
- D. Insertion of an intravenous (IV) line
Correct Answer: A
Rationale: Until the cause of the acute abdominal syndrome is determined and a decision about the need for surgery is made, the nurse would question a prescription to give a clear liquid diet. The nurse can expect the client to be placed on NPO status and to have an IV line inserted. Insertion of a nasogastric tube may be helpful to provide decompression of the stomach. Pain management with medications that do not alter level of consciousness can decrease diffuse abdominal pain and rigidity, help with localizing the pain, and lead to more prompt diagnosis and treatment.
Which situation represents the primary nursing care delivery model?
- A. The registered nurse (RN) performs all tasks needed by the individual client to optimize health.
- B. The RN provides care to 4 clients, while the unlicensed assistive personnel (UAP) is assigned to care for 2 clients.
- C. The RN develops a plan of care for each client and collaborates with other staff members assigned to the same group of clients.
- D. The UAP is assigned to make beds and fill water pitchers. The RN is assigned to administer medications.
Correct Answer: A
Rationale: In primary nursing, option 1, concern is with keeping the nurse at the bedside actively involved in care, providing goal-directed and individualized client care. Option 2 does not follow the guidelines for any specific type of nursing care delivery approach. Team nursing, option 3, is characterized by a high degree of communication and collaboration among members. The team is generally led by an RN, who is responsible for assessing, developing nursing diagnoses, planning, and evaluating each client's plan of care. The functional model of care involves an assembly line approach to client care, with major tasks being delegated by the charge nurse to individual staff members.
The medication nurse is supervising a newly hired licensed practical nurse (LPN) during the administration of prescribed oral pyridostigmine bromide to a client with a diagnosis of myasthenia gravis. Which observation by the medication nurse indicates safe practice by the LPN?
- A. Asking the client to take sips of water
- B. Asking the client to lie down on his right side
- C. Asking the client to look up at the ceiling for 30 seconds
- D. Instructing the client to void before taking the medication
Correct Answer: A
Rationale: Myasthenia gravis can affect the client's ability to swallow. The primary assessment is to determine the client's ability to handle oral medications or any oral substance. Options 2 and 3 are not appropriate. Option 2 could result in aspiration, and option 3 has no useful purpose. There is no specific reason for the client to void before taking this medication.
A home care nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further instruction?
- A. I need to use the back burners for cooking.
- B. I need to remain in the kitchen when I prepare meals.
- C. I need to be sure to place my cup of coffee on the counter.
- D. I need to turn pot handles inward and to the middle of the stove.
Correct Answer: C
Rationale: Toddlers, with their increased mobility and developing motor skills, can reach hot water or hot objects placed on counters and open fires or burners on stoves above their eye level. The mother's statement in option 3 does not indicate an adequate understanding of the principles of safety. Hot liquids should never be left unattended, and the toddler should always be supervised. Parents should be encouraged to use the back burners on the stove, remain in the kitchen when preparing a meal, and turn pot handles inward and toward the middle of the stove.
A 17-year-old client is discharged to home with her newborn baby after the nurse provides information about home safety for children. Which statement by the client should alert the nurse that further teaching is required regarding home safety?
- A. I can keep my aluminum pots and pans in my lower cabinets.
- B. I will not use the microwave oven to heat my baby's formula.
- C. I have locks on all my cabinets that contain my cleaning supplies.
- D. I have a car seat that I will put in the front seat to keep my baby safe.
Correct Answer: D
Rationale: A baby car seat should never be placed in the front seat because of the potential for life-threatening injury on impact. It is perfectly safe to leave pots and pans in the lower cabinets for a child to investigate, as long as they are not made of glass, which would harm the baby if broken. Microwave ovens should never be used to heat formula because the formula heats unevenly, and it could burn and even scald the baby's mouth. Even though the bottle may feel warm, it could contain hot spots that could severely damage the baby's mouth. Any cabinets that contain dangerous items that a baby or child could swallow should be locked.