Nokea
The nurse is administering lidocaine (Xylocaine) to a client with a myocardial infarction. Which of the following assessment findings requires the nurse's immediate action?
- A. Central venous pressure reading of 11
- B. Respiratory rate of 22
- C. Pulse rate of 48 BPM
- D. Blood pressure of 144/92
Correct Answer: C
Rationale: One of the side effects of lidocaine is bradycardia, heart block, cardiovascular collapse and cardiac arrest (this drug should never be administered without continuous EKG monitoring).
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The nurse should include which of the following in a teaching plan for a client receiving tetracycline?
- A. Take the medication with milk or antacids to decrease GI problems.
- B. The medication should always be taken with meals.
- C. Use a maximum-protection sunscreen when outdoors.
- D. Crackers and juice will help decrease gastric irritation.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) tetracycline should never be taken with milk or antacids as these inhibit the medication's action (2) should take with full glass of water at least one hour before or two hours after meals (3) correct-because of problems related to photosensitivity, sunscreen, wide-brimmed hats, and long sleeves should be worn when client is at risk for sun exposure (4) should take with full glass of water at least one hour before or two hours after meals
The care of which of the following clients can the nurse safely delegate to an unlicensed assistive personnel (UAP)?
- A. A client with peripheral vascular disease and an ulceration of the lower leg.
- B. A pre-operative client awaiting adrenalectomy with a history of asthma
- C. An elderly client with hypertension and self-reported non-compliance
- D. A new admission with a history of transient ischemic attacks and dizziness
Correct Answer: A
Rationale: This client is stable with no risk of instability as compared to the other clients. The client has a chronic condition and needs supportive care, which is appropriate for a UAP.
The nurse knows which of the following would be MOST likely to help the family of an emotionally disturbed client manage behaviors at home after discharge from inpatient treatment?
- A. Refer the family to Alliance for the Mentally Ill meetings for educational programs and support groups.
- B. Provide the family with pamphlets that describe the desired action and side effects of medications the client is taking.
- C. Tell the family that it is not their fault that the client behaves inappropriately.
- D. Involve the family in the assessment of the client when s/he is first admitted to the hospital.
Correct Answer: A
Rationale: The Alliance for the Mentally Ill offers ongoing education and support groups, equipping families with skills to manage behaviors long-term. Pamphlets, reassurance, and early involvement are helpful but lack the sustained impact of a support network.
The nurse is to obtain pedal pulses on a client following a cardiac catheterization. Which is the proper procedure?
- A. Place the fingertips against the wrist bone.
- B. Place the stethoscope over the apex of the heart.
- C. Place the fingertips against the side of the neck.
- D. Place the fingertips on top of the foot.
Correct Answer: D
Rationale: Pedal pulses are assessed by palpating the dorsalis pedis or posterior tibial arteries on the foot, checking for circulation post-catheterization.
During the rehabilitative phase, the client's burns become infected with pseudomonas. The topical dressing most likely to be ordered for the client is:
- A. Silver sulfadiazine (Silvadene)
- B. Poviodine (Betadine)
- C. Mafenide acetate (Sulfamylon)
- D. Silver nitrate
Correct Answer: C
Rationale: Mafenide acetate (Sulfamylon) is particularly effective against Pseudomonas infections due to its broad-spectrum antibacterial activity and ability to penetrate eschar. Silver sulfadiazine is less effective against Pseudomonas, and povidone-iodine and silver nitrate are not the primary choices for Pseudomonas infections. Answers A, B, and D are incorrect because they are less effective for this specific infection.