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The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority?
- A. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles.
- B. Confusion, urine output 15 mL over the last 2 hours, orthopnea.
- C. SpO2 92 on 2 liters nasal cannula, respirations 20, 1+ edema of lower extremities.
- D. Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise.
Correct Answer: B
Rationale: Confusion, low urine output, and orthopnea indicate severe heart failure with potential cerebral and renal hypoperfusion, requiring immediate intervention. Other options reflect stable or less urgent findings.
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The American Heart Association (AHA) guidelines urge greater availability of automated external defibrillators (AEDs) and people trained to use them. AEDs are used in cardiac arrest situations for:
- A. Early defibrillation in cases of atrial fibrillation.
- B. Cardiovascular placement.
- C. Early defibrillation in cases of ventricular fibrillation.
- D. None of the above
Correct Answer: C
Rationale: AEDs are used for early defibrillation in ventricular fibrillation or pulseless ventricular tachycardia, as these are shockable rhythms that can be corrected to restore cardiac function.
A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following are goals for the care for this client? Select all that apply.
- A. Preventing constipation.
- B. Administering lactulose (Cephulac).
- C. Monitoring coordination while walking.
- D. Checking the pupil reaction.
- E. Increasing food and fluids high in carbohydrate.
- F. Encouraging physical activity.
Correct Answer: A,B
Rationale: Preventing constipation (A) and administering lactulose (B) reduce ammonia levels in hepatic encephalopathy. Coordination (C) and pupil reaction (D) are less relevant. High carbohydrates (E) are not specific, and physical activity (F) may be limited.
Two days after surgery, a client continues to take hydrocodone 7.5 mg and acetaminophen 500 mg (Lortab 7.5/500). What should the nurse ask the client before administering the pain medication?
- A. œWhere is your pain located?'
- B. œHave you emptied your bladder?'
- C. œHow long has it been since your last dose?'
- D. œIs your pain better than before you had surgery?'
Correct Answer: C
Rationale: Asking about the time since the last dose ensures safe administration, preventing overdose or toxicity, as hydrocodone has a specific dosing interval.
To provide oral hygiene for a client recovering from transsphenoidal hypophysectomy, the nurse should instruct the client to:
- A. Rinse the mouth with saline solution.
- B. Perform frequent toothbrushing.
- C. Clean the teeth with an electric toothbrush.
- D. Floss the teeth thoroughly.
Correct Answer: A
Rationale: Saline mouth rinses are gentle and safe post-transsphenoidal hypophysectomy, avoiding irritation to the surgical site.
The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1" × 1" area on his sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the chart?
- A. Stage I pressure ulcer.
- B. Stage II pressure ulcer.
- C. Stage III pressure ulcer.
- D. Stage IV pressure ulcer.
Correct Answer: B
Rationale: A Stage II pressure ulcer involves partial-thickness skin loss extending to the dermis, matching the description of the sacral breakdown.