Nokea
The nurse is caring for a 45-year-old client with atrial fibrillation who has been receiving diltiazem. Which of the following findings would indicate that the medication has been effective?
- A. Blood pressure of 126/78 mm Hg
- B. Client does not have chest pain
- C. Client has not experienced any signs of stroke
- D. Ventricular rate decreased from 158/min to 88/min
Correct Answer: D
Rationale: Diltiazem is used in atrial fibrillation to control ventricular rate. A decrease from 158/min to 88/min indicates effective rate control. Blood pressure, chest pain, and stroke prevention are not primary indicators of diltiazem's efficacy in this context.
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The nurse has attended a staff education program about ethical practices in nursing. Which of the following statements by the nurse would indicate a correct understanding of the program? Select all that apply.
- A. Accountability is notifying the health care provider after making a medication error.
- B. Autonomy is informing the client of the care decisions the family has made for the client.
- C. Confidentiality is respecting a client's request to keep suicidal ideation a secret from other members of the health care team.
- D. Fidelity is returning to the client's room with pain medication at the time that was promised to the client.
- E. Nonmaleficence is reporting suspected elder abuse of a client with Alzheimer disease.
Correct Answer: A,D,E
Rationale: Accountability involves taking responsibility for errors (A). Fidelity is keeping promises, such as timely medication delivery (D). Nonmaleficence includes preventing harm by reporting abuse (E). Autonomy respects the client's decision-making, not family decisions (B), and confidentiality does not extend to withholding suicidal ideation, which requires intervention (C).
A 5-year old with a suspected ventricular septal defect is scheduled for a cardiac catheterization. The child's mother asks the nurse, 'Why does my little girl have to have that tube put into her heart?' The nurse should tell the mother that the cardiac catheterization will:
- A. Identify how much her heart is enlarged
- B. Show the size and exact location of the defect
- C. Show whether the ventricles are enlarged
- D. Determine the existence of a murmur
Correct Answer: B
Rationale: Cardiac catheterization visualizes the heart's structures, allowing precise identification of the size and location of a ventricular septal defect.
Which of the following solutions is routinely used to flush an IV device before and after the administration of blood to a client?
- A. 0.9% sodium chloride
- B. 5% dextrose in water solution
- C. sterile water
- D. Heparin sodium
Correct Answer: A
Rationale: 0.9% sodium chloride (normal saline) is isotonic and compatible with blood, preventing cell lysis or clotting during IV flushing. The other solutions are inappropriate for this purpose. Pharmacological Therapies
The nurse in the emergency department is caring for a client who is experiencing an acute exacerbation of asthma. Which of the following medications should the nurse expect to administer?
- A. Nebulized albuterol
- B. PO montelukast sodium
- C. IV methylprednisolone succinate
- D. Inhaled ipratropium
- E. Inhaled salmeterol
Correct Answer: A
Rationale: Nebulized albuterol, a short-acting beta-agonist, rapidly relieves bronchospasm in acute asthma exacerbations. Montelukast is for maintenance, methylprednisolone is slower-acting, ipratropium is secondary, and salmeterol is long-acting, not for acute relief.
A nurse auscultates a loud cardiac murmur on a newborn with suspected trisomy 21 (Down syndrome). A genetic screen and an echocardiogram are scheduled that day. The neonate’s vital signs are shown in the exhibit. What would be an appropriate action for the nurse to complete next?
- A. Call the health care provider immediately
- B. Document the finding
- C. Place the neonate in a knee-chest position
- D. Provide oxygen to the neonate
Correct Answer: B
Rationale: Documenting the murmur is appropriate as genetic screening and an echocardiogram are already scheduled, indicating the provider is aware. Calling the provider is unnecessary, knee-chest position is for specific heart defects, and oxygen is not indicated without respiratory distress.