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. Atrial fibrillation.
- D. Ventricular tachycardia.
Correct Answer: C
Rationale: Without the strip, atrial fibrillation is assumed for its common occurrence and need for monitoring in a test context.
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The nurse has explained the reason that the primary health care provider has chosen laser surgery to treat a client's cervical cancer. Which statement by the client indicates an understanding of the explanation?
- A. I want to be asleep during my procedure.
- B. I have too much cancer to be removed with surgery.
- C. I am young and the laser prevents cancer tissue from re-growing.
- D. The primary health care provider is able to see all the edges of my cancer clearly.
Correct Answer: D
Rationale: Laser therapy is performed in an outpatient setting and is used when all boundaries of the lesion are visible. Laser surgery is painless, and the client would not receive general anesthesia. Laser therapy does not prevent regrowth.
The nurse performs an assessment on a client with cancer and notes that the client is receiving pain medication via this type of catheter. (Refer to the figure.) What should the nurse document that the client has?
- A. Epidural catheter
- B. Hickman catheter
- C. Central venous catheter (CVC)
- D. Patient-controlled analgesia (PCA) pump
Correct Answer: A
Rationale: An epidural catheter is placed in the epidural space. The epidural space lies between the dura mater and the vertebral column. When an opioid is injected into the epidural space, it binds to opiate receptors located on the dorsal horn of the spinal cord and blocks the transmission of pain impulses to the cerebral cortex of the brain. Because the opioid does not cross the blood-brain barrier, pain relief results from drug levels in the spinal cord rather than in the plasma, with little central or systemic distribution of the medication. A Hickman catheter is a vascular access device that is surgically inserted, tunneled through the subcutaneous tissue, and is used to manage long-term intravenous therapy. A CVC is inserted into a large vein (typically the internal or external jugular or the superior vena cava) that leads to the right atrium of the heart. A PCA pump is the device that allows the client to self-administer pain medication.
A loading dose of digoxin (Lanoxin) is given to a client newly diagnosed with atrial fibrillation. The nurse begins instruction in the medication and the importance of monitoring his heart rate. An expected outcome of the education program will be:
- A. A return demonstration of palpating the radial pulse.
- B. A return demonstration of how to take the medication.
- C. Verbalization of why the client has atrial fibrillation.
- D. Verbalization of the need for the medication.
Correct Answer: A
Rationale: Teaching the client to monitor their radial pulse ensures they can detect irregularities or bradycardia, a critical aspect of managing digoxin therapy.
A client diagnosed with chronic kidney disease has been prescribed epoetin alfa. The nurse reminds the client about the importance of taking which prescribed medication to enhance the effects of this therapy?
- A. Ferrous gluconate
- B. Calcium carbonate
- C. Aluminum carbonate
- D. Aluminum hydroxide gel
Correct Answer: A
Rationale: To form healthy red blood cells, which is the purpose of epoetin alfa, the body needs adequate stores of iron, folic acid, and vitamin B12. The client should take these ferrous gluconate supplements regularly to enhance the hematocrit-raising benefit of this medication. The other options are unnecessary medications.
The nurse is discussing safety and accident prevention with the mother of a 9-month-old. The teaching has been effective when the mother states which of the following?
- A. I make sure that I keep my cleaning supplies locked up.'
- B. Sometimes she plays in the bathroom when I'm cleaning in there.'
- C. Occasionally she gets under the chair and plays with the telephone cord.'
- D. I've found that those child-protective cabinet locks don't work very well.'
Correct Answer: A
Rationale: Keeping cleaning supplies locked up indicates effective teaching on safety, as it prevents the child from accessing hazardous substances.