Nokea
The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifies this rhythm as which of the following?
- A. Atrial fibrillation.
- B. Ventricular tachycardia.
- C. Premature ventricular contractions (PVCs).
- D. Third-degree heart block.
Correct Answer: N/A
Rationale: Without the ECG strip, the rhythm cannot be identified. This question is incomplete in the provided document.
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Which of the following is an environmental factor and increases the risk of cancer?
- A. Gender.
- B. Nutrition.
- C. Immunologic status.
- D. Age.
Correct Answer: B
Rationale: Nutrition is an environmental factor that influences cancer risk, as diets high in processed foods or low in fiber can increase the risk of cancers like colon cancer.
When comparing the hematocrit levels of a postoperative client, the nurse notes that the hematocrit decreased from 36% to 34% on the third day even though the RBC count and hemoglobin value remained within 10 mg/dL and 11.9 g/dL, respectively. The nurse should:
- A. Check the dressing and drains for frank bleeding.
- B. Call the physician.
- C. Continue to monitor vital signs.
- D. Start oxygen at 2 L/minute per nasal cannula.
Correct Answer: C
Rationale: A slight decrease in hematocrit (36% to 34%) on postoperative day 3, with stable RBC count and hemoglobin, is likely due to hemodilution from fluid administration rather than active bleeding. The nurse should continue to monitor vital signs and hematologic parameters. Checking for bleeding is unnecessary without signs of hemorrhage, calling the physician is premature, and oxygen is not indicated.
Which of the following findings is the best indication that fluid replacement for the client in hypovolemic shock is adequate?
- A. Urine output greater than 30 mL/hour.
- B. Systolic blood pressure greater than 110 mm Hg.
- C. Diastolic blood pressure greater than 90 mm Hg.
- D. Respiratory rate of 20 breaths/minute.
Correct Answer: A
Rationale: Adequate fluid replacement in hypovolemic shock is best indicated by a urine output greater than 30 mL/hour, reflecting restored renal perfusion. Blood pressure and respiratory rate improvements are supportive but less specific.
Which complication should the nurse monitor for in a client with a new ileal conduit?
- A. Stoma prolapse.
- B. Urinary retention.
- C. Bladder spasms.
- D. Renal colic.
Correct Answer: A
Rationale: Stoma prolapse is a potential complication of an ileal conduit, requiring surgical correction if severe.
A client is eligible for patient-controlled analgesia (PCA) when:
- A. A family member is able to assist with self-dosing.
- B. There is a court-appointed advocate to assist with self-dosing.
- C. The client has the ability to self-dose.
- D. There is a nurse to assist with self-dosing.
Correct Answer: C
Rationale: PCA requires the client to have the cognitive and physical ability to self-dose, ensuring safe and effective pain management.