Nokea
The nurse is administering morning medications. Which medication should be administered first?
- A. The cardiac glycoside medication, digoxin, to a client diagnosed with heart failure and who has 2+ edema of the feet.
- B. The sliding scale insulin to a client with a fasting blood glucose of 345 mg/dL who is demanding breakfast.
- C. The loop diuretic, furosemide, to a client with a 24-hour intake of 986 mL and an output of 1,400 mL.
- D. The ARB medication to a client whose blood pressure was reported by the unlicensed assistive personnel as 142/76.
Correct Answer: B
Rationale: Fasting glucose of 345 mg/dL (B) requires immediate insulin to prevent complications, especially before eating. Digoxin (A), furosemide (C), and ARB (D) are less urgent.
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The client is in ventricular fibrillation. Which interventions should the nurse implement? Select all that apply.
- A. Start cardiopulmonary resuscitation.
- B. Prepare to administer the antidysrhythmic adenosine IVP.
- C. Prepare to defibrillate the client.
- D. Bring the crash cart to the bedside.
- E. Prepare to administer the antidysrhythmic amiodarone IVP.
Correct Answer: A,C,D,E
Rationale: Ventricular fibrillation requires CPR (A), defibrillation (C), crash cart (D), and amiodarone (E). Adenosine (B) is for SVT.
Which client problem has priority for the client with a cardiac dysrhythmia?
- A. Alteration in comfort.
- B. Decreased cardiac output.
- C. Impaired gas exchange.
- D. Activity intolerance.
Correct Answer: B
Rationale: Dysrhythmias primarily reduce cardiac output (B), impacting perfusion, making it the priority. Comfort (A), gas exchange (C), and activity (D) are secondary.
The client with a mechanical valve replacement asks the nurse, 'Why do I have to take antibiotics before getting my teeth cleaned?' Which response by the nurse is most appropriate?
- A. You are at risk of developing an infection in your heart.'
- B. Your teeth will not bleed as much if you have antibiotics.'
- C. This procedure may cause your valve to malfunction.'
- D. Antibiotics will prevent vegetative growth on your valves.'
Correct Answer: A
Rationale: Mechanical valves increase endocarditis risk; antibiotics (A) prevent heart infection during dental procedures. Bleeding (B), valve malfunction (C), and vegetative growth (D) are inaccurate.
The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?
- A. Assist the client to go down to the smoking area for a cigarette.
- B. Transport the client to the intensive care unit (ICU) via a stretcher.
- C. Provide the client going home discharge-teaching instructions.
- D. Help position the client who is having a portable x-ray done.
Correct Answer: D
Rationale: Positioning for an x-ray (D) is within the UAP’s scope and safe. Smoking (A) is inappropriate, ICU transport (B) requires nursing judgment, and discharge teaching (C) is a nursing responsibility.
The client is admitted to the medical unit to rule out carditis. Which question should the nurse ask the client during the admission interview to support this diagnosis?
- A. Have you had a sore throat in the last month?'
- B. Did you have rheumatic fever as a child?'
- C. Do you have a family history of carditis?'
- D. What over-the-counter (OTC) medications do you take?'
Correct Answer: B
Rationale: Rheumatic fever (B) is a major cause of carditis, especially in children, making it the most relevant question. Sore throat (A) is less specific, family history (C) is rare, and OTC meds (D) are unrelated.