Nokea
The nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction. The first action the nurse would perform is to
- A. Begin cardiopulmonary resuscitation
- B. Prepare for immediate defibrillation
- C. Notify the 'Code' team and provider
- D. Assess airway breathing and circulation
Correct Answer: D
Rationale: Assess airway breathing and circulation. The nurse must first assess the client to determine the appropriate next step. In this case the first step the nurse must take is to evaluate the A, B, C’s.
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Which of the actions suggested to the registered nurse (RN) by the practical nurse (PN) during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care?
- A. Measure head circumference
- B. Place in airborne isolation
- C. Provide passive range of motion
- D. Provide an over-the-crib protective top
Correct Answer: A
Rationale: Measure head circumference. This monitors for complications like hydrocephalus in meningitis.
A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect when assessing this client?
- A. Hyperextension of the neck with passive shoulder flexion
- B. Flexion of the hip and knees with passive flexion of the neck
- C. Flexion of the legs with rebound tenderness
- D. Hyperflexion of the neck with rebound flexion of the legs
Correct Answer: B
Rationale: Flexion of the hip and knees with passive flexion of the neck. This is a positive Brudzinski's sign, indicative of meningitis.
A 48-year-old woman is seen in the outpatient clinic for complaints of irregular menses.
- A. What is the most probable cause of irregular menses in a 48-year-old woman with a history of regular periods?
- B. Emotional trauma and stress.
- C. The onset of menopause.
- D. The presence of uterine fibroids.
- E. A possible tubal pregnancy.
Correct Answer: B
Rationale: Irregular menses in a 48-year-old woman is most likely due to menopause, as ovarian function declines between ages 45- Stress lacks supporting data, fibroids cause excessive bleeding, and tubal pregnancy typically presents with missed periods and pain.
A client develops severe, crushing chest pain radiating to the left shoulder and arm.
Which of the following PRN medications should the nurse administer?
- A. Diazepam (Valium) PO.
- B. Meperidine (Demerol) IM.
- C. Morphine sulfate IV.
- D. Nitroglycerine (Nitrostat) SL.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not an appropriate medication in this situation; antianxiety medication (2) Demerol is less commonly used because it may induce vomiting and initiate a vagal response (3) correct-morphine sulfate is given to reduce pain, anxiety, and cardiac workload; reduces the preload and afterload pressures (4) although a client at home may have taken NTG SL, the nurse would administer it IV to reduce pain and decrease overload
An adult is being discharged from the emergency room with instructions to apply a cold pack to his sprained ankle. The client asks why it is necessary to use a cold pack. The nurse replies that the cold pack will do which of the following?
- A. Keep the sprain from becoming a fracture
- B. Prevent bruising and ecchymosis from occurring
- C. Keep the client from developing a fever
- D. Help reduce swelling and pain
Correct Answer: D
Rationale: Cold packs reduce swelling and pain by constricting blood vessels and numbing the area, aiding sprain recovery. They don't prevent fractures, bruising, or fever.