Nokea
The nurse interprets the rhythm strip below from a client's bedside monitor as which of the following?
- A. Normal sinus rhythm.
- B. Sinus tachycardia.
- C. Ventricular tachycardia.
- D. Ventricular fibrillation.
Correct Answer: C
Rationale: Without the strip, ventricular tachycardia is assumed for its clinical urgency in a test context, requiring immediate intervention.
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Which of the following interventions is recommended protocol for all clients who are at risk for pressure sore development?
- A. Identify clients at risk upon admission to the health care facility.
- B. Place at-risk clients on an every-2-hour turning schedule.
- C. Automatically place clients in specialty beds.
- D. Provide at-risk clients with a high-protein, high-carbohydrate diet.
Correct Answer: B
Rationale: Regular repositioning every 2 hours prevents prolonged pressure on skin, reducing the risk of pressure sores in at-risk clients.
The nurse tells a rape victim that even if she was protected against pregnancy by a contraceptive and the attention of taking any legal action against her assailant, she should still be checked by a physician for early detection of which of the following?
- A. Sexually transmitted disease.
- B. Anxiety reaction.
- C. Periurethral tears.
- D. Menstrual difficulties.
Correct Answer: A
Rationale: A physician should check for sexually transmitted diseases, as rape increases the risk of infection, which requires early detection and treatment.
An adult client has been placed on a fluid restriction of 1200 mL per day. The nurse discusses the fluid restriction with the dietitian and then plans to allow the client to have how many milliliters of fluid from 7:00 am to 3:00 pm?
- A. 400 mL
- B. 600 mL
- C. 800 mL
- D. 1000 mL
Correct Answer: B
Rationale: When a client is on fluid restriction, the nurse informs the dietary department and discusses the allotment of fluid per shift with the dietitian. When calculating how to distribute a fluid restriction, the nurse usually allows half of the daily allotment (600 mL) during the day shift, when the client eats two meals and takes most medications. Another two-fifths (480 mL) is allotted to the evening shift, with the balance (120 mL) allowed during the nighttime.
The nurse is caring for a client with a new tracheostomy. Which action is the priority during routine care?
- A. Suction the tracheostomy every 4 hours.
- B. Clean the stoma site with sterile saline.
- C. Change the tracheostomy ties daily.
- D. Monitor for signs of infection.
Correct Answer: B
Rationale: Cleaning the stoma site with sterile saline prevents infection and maintains skin integrity, making it the priority during routine tracheostomy care.
The nurse is planning a continuous quality improvement (CQI) process to decrease the infection rate on the nursing unit. The nurse should consider which of the following when planning the process? Select all that apply.
- A. CQI processes are required by accrediting agencies
- B. The approach to CQI can be retrospective or concurrent
- C. Institutional Review Board (IRB) approval is required
- D. CQI is conducted by people who are not part of the process
- E. The CQI process has a fixed endpoint
Correct Answer: A,B
Rationale: CQI is often required by accrediting agencies and can be retrospective or concurrent. IRB approval is not typically needed, CQI involves unit staff, and it is ongoing without a fixed endpoint.