Nokea
The nurse has received report on the day's assigned clients. Which of the following clients should the nurse see first?
- A. a client who is post-op day 2 from a spinal fusion at L34 with a pain level of 4 on a scale of 1-10
- B. a client with a peripheral IV on a 6-hour infusion with 42 cc remaining
- C. a client who is 6 hours post-atrial fibrillation ablation, is agitated, has a HR of 130 with B/P at 90/50, and has a urine output of 30 cc in the last 2 hours
- D. a client with a nasogastric tube in place who is complaining of gastric distress
Correct Answer: C
Rationale: The client post-atrial fibrillation ablation with agitation, tachycardia (HR 130), hypotension (BP 90/50), and low urine output (30 cc in 2 hours) indicates potential instability, requiring immediate assessment. This takes priority over stable post-op pain, an IV with remaining fluid, or gastric distress.
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A client in the ICU is given procainamide HCl (Pronestyl) slowly IV push. The nurse should withhold the next dose of this medication and notify the physician if which of the following is observed on the cardiac monitor?
- A. One premature ventricular contraction (PVC).
- B. Sinus rhythm with occasional bigeminy.
- C. Persistent tachycardia of 112 beats per minute.
- D. Prolongation of the QT interval.
Correct Answer: D
Rationale: prolongation of the QT interval is a side effect that can lead to torsades de pointes, a life-threatening arrhythmia
Which clients can be assigned to share a room in the emergency department during the disaster?
- A. A client having auditory hallucinations and the client with ulcerative colitis
- B. The client who is pregnant and the client with a broken arm
- C. A child who is cyanotic with severe dypsnea and a client with a frontal head injury
- D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain
Correct Answer: B
Rationale: The pregnant client and the client with a broken arm have stable conditions, making them suitable to share a room.
Which nursing assessment indicates that involutional changes have occurred in a client who is 3 days postpartum?
- A. The fundus is firm and 3 finger widths below the umbilicus.
- B. The client has a moderate amount of lochia serosa.
- C. The fundus is firm and even with the umbilicus.
- D. The uterus is approximately the size of a small grapefruit.
Correct Answer: A
Rationale: A firm fundus 3 finger widths below the umbilicus by day 3 postpartum indicates normal uterine involution, as the uterus shrinks progressively after delivery.
A client seen in the emergency department for influenza asks for an antibiotic prescription. Which of the following guidelines are important in helping the client decrease the risk of developing an antibiotic-resistant infection? Select all that apply.
- A. Stop taking antibiotics as soon as symptoms subside.
- B. Do not take antibiotics for viral infections, as they do no good.
- C. Do not take preventive antibiotics to avoid infection.
- D. Follow prescription directions when taking antibiotics.
- E. Take the same antibiotic for every infection.
Correct Answer: B,C,D
Rationale: Avoid antibiotics for viral infections (B), avoid prophylactic antibiotics (C), and follow prescription directions (D) reduce resistance. Stopping early (A) or reusing antibiotics (E) promotes resistance.
The nurse in an ambulatory care clinic is admitting a 27-year-old client with severe systemic lupus erythematosus (SLE). In assessing the client's health history, the nurse knows to question which of the following statements?
- A. I avoid being outside on sunny days.
- B. The medications I take make me bloated.
- C. My work schedule is down to four hours a day.
- D. I get an eye exam annually.
Correct Answer: D
Rationale: Annual eye exams may not be sufficient for SLE, as the condition and its treatments can cause frequent eye complications, requiring more regular monitoring.