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 is teaching a client who has short-term memory loss how to use the call light. Which factor is least essential for the nurse to assess when teaching this client?
- A. Visual status
- B. Ambulatory difficulty
- C. Orientation to time, place, and person
- D. Understanding of the English language
Correct Answer: B
Rationale: Ambulatory difficulty is least relevant, as call light use relies on vision, orientation, and language comprehension, not mobility.
During the physical assessment, the nurse determines the need to perform the bulge Test .
Which of the following statements, if made by the nurse, is BEST?
- A. Please lie down and extend your legs.
- B. Please bend over and touch your toes.
- C. Please hold both hands behind your back.
- D. Please bend your elbow.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-bulge Test confirms presence of fluid in the knee; client's leg should be extended and supported on the bed (2) observing curve of spine; scoliosis will cause lateral curve in the spine (3) unrelated to knee examination (4) Test s articulation of elbow
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.
A client with newly diagnosed diabetes mellitus.
Which of the following statements, if made by the client to the nurse, would indicate that further teaching is necessary?
- A. I should cut my toenails straight across.
- B. I should not go barefoot.
- C. I should inspect my feet once a week.
- D. I should bathe my feet daily in warm water.
Correct Answer: C
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) prevents ingrown nails (2) prevents possible injury to feet (3) correct-should inspect feet daily for blisters, sores, ingrown nails, and cuts (4) proper care
A client with chronic congestive heart failure should be instructed to contact the home health nurse if which finding occurs?
- A. Weight gain of 2 pounds or more in a 48 hour period
- B. Urinating 4 to 5 times each day
- C. A significant decrease in appetite
- D. Appearance of non-pitting ankle edema
Correct Answer: A
Rationale: Weight gain of 2 pounds or more in a 48 hour period. It is critical for clients to report and be treated for rapid weight gain, which indicates fluid retention and worsening heart failure.