Nokea
The nurse discovers that a hospitalized client is not breathing and has no pulse. After calling for help, what should the nurse do next?
- A. Give the client two breaths
- B. Administer five chest compressions
- C. Go get the emergency cart
- D. Defibrillate the client
Correct Answer: A
Rationale: Per CPR guidelines, after calling for help, provide two rescue breaths if trained, followed by compressions. Fetching the cart or defibrillating delays resuscitation.
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The nurse assesses the development of a three-month-old boy in the well-baby clinic.
- A. Which behavior in a three-month-old boy would be unexpected?
- B. The boy holds his head erect when sitting on the examination table.
- C. The boy tries to grasp a toy just out of reach.
- D. The boy turns his head to try to locate a sound.
- E. The boy smiles spontaneously when he sees his mother.
Correct Answer: B
Rationale: Grasping for objects out of reach is unexpected until around 6 months of age. Holding the head erect, turning toward sounds, and spontaneous smiling are developmentally appropriate for a three-month-old.
The nurse is caring for a client with a history of rheumatoid arthritis who is receiving prednisone 10 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Weight gain of 5 pounds in a month.
- C. Occasional joint stiffness.
- D. Mild headache.
Correct Answer: B
Rationale: Weight gain of 5 pounds in a month suggests prednisone-induced fluid retention, requiring evaluation. Options A, C, and D are less urgent.
The nurse is caring for a client with a history of anaphylaxis.
- A. Which instruction is most important for a client with a history of anaphylaxis?
- B. Carry an epinephrine auto-injector at all times.
- C. Avoid over-the-counter medications.
- D. Wear loose-fitting clothing.
- E. Monitor blood pressure daily.
Correct Answer: A
Rationale: Carrying an epinephrine auto-injector is critical for immediate treatment of anaphylaxis, a life-threatening allergic reaction. Avoiding medications, wearing loose clothing, and monitoring blood pressure are less urgent.
The nurse is administering lidocaine (Xylocaine) to a client with a myocardial infarction. Which of the following assessment findings requires the nurse's immediate action?
- A. Central venous pressure reading of 11
- B. Respiratory rate of 22
- C. Pulse rate of 48 BPM
- D. Blood pressure of 144/92
Correct Answer: C
Rationale: One of the side effects of lidocaine is bradycardia, heart block, cardiovascular collapse and cardiac arrest (this drug should never be administered without continuous EKG monitoring).
Which of the following is the BEST method for the nurse to use when evaluating the effectiveness of tracheal suctioning?
- A. Note subjective data, such as 'My breathing is much improved now.'
- B. Note objective findings, such as decreased respiratory rate and pulse.
- C. Consult with the respiratory therapist to determine effectiveness.
- D. Auscultate the chest for change or clearing of adventitious breath sounds.
Correct Answer: D
Rationale: to assess the effectiveness of suctioning, auscultate the client's chest to determine if the adventitious sounds are cleared and to ensure that the airway is clear of secretions.