Nokea
The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?
- A. Diminished bowel sounds
- B. Loss of appetite
- C. A cold, pale lower leg
- D. Tachypnea
Correct Answer: C
Rationale: A cold, pale lower leg. This assessment suggests the presence of an embolus probably from the atrial fibrillation. Peripheral pulses should be checked immediately.
You may also like to solve these questions
The nursing student approaches the instructor after being stuck by a bloody needle. Which instructor statement is most accurate knowing that the client was HIV-positive?
- A. "Wash with soap and water and see the HCP now; treatment should begin within 1 to 2 hours."
- B. "The first HIV antibody testing is completed in 6 weeks and then repeated in 3 months."
- C. "Wash with soap and water now. At the end of the clinical shift, notify your physician."
- D. "Flush immediately with water for 10 minutes and then cover with a bandage and glove."
Correct Answer: A
Rationale: A: Immediate washing and HCP evaluation within 1-2 hours are critical for post-exposure prophylaxis. B: Testing timing is incorrect. C: Delaying care is risky. D: Flushing is for mucosal exposure.
Which information is most important for the nurse to reinforce with a male client who is about to undergo a vasectomy?
- A. Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.'
- B. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate.'
- C. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you may return to work as soon as you feel up to it.'
- D. The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort.'
Correct Answer: A
Rationale: All of these options are correct information. The most important point to reinforce is the continuing need to take additional action for birth control until the absence of sperm in the ejaculate is confirmed.
A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug?
- A. Diaphoresis with decreased urinary output
- B. Increased heart rate with increased respirations
- C. Improved respiratory status and increased urinary output
- D. Decreased chest pain and decreased blood pressure
Correct Answer: C
Rationale: Improved respiratory status and increased urinary output. Digoxin, a cardiac glycoside, is used in clients with heart failure to slow and strengthen the heartbeat. As cardiac output is improved, renal perfusion is improved and urinary output increases. Clients can become toxic on this drug, indicated by findings of bradycardia, dysrhythmia, and visual and GI disturbances.
The nurse is caring for the client with an IV. Which findings should prompt the nurse to conclude that the client is experiencing inflammation (phlebitis) at the IV insertion site? Select all that apply.
- A. Pain
- B. Redness
- C. Warmth
- D. Drainage
- E. Mottling
- F. Swelling
Correct Answer: A,B,C,F
Rationale: A: Pain indicates tissue irritation. B: Redness results from vasodilation. C: Warmth is caused by inflammation. F: Swelling occurs from fluid leakage. D: Drainage suggests infection. E: Mottling is unrelated.
The charge nurse is assigning staff to care for the client with disseminated herpes zoster. Which staff member should the charge nurse exclude from being assigned?
- A. A 7-month pregnant nurse who had confirmed chicken pox in childhood
- B. A 32-year-old nurse with unknown disease or vaccination history for chicken pox
- C. A 28-year-old nurse with a history of varicella vaccine and 2 small children at home
- D. A 60-year-old nurse with a history of live herpes zoster vaccine
Correct Answer: B
Rationale: B: Unknown immunity status poses a risk of varicella infection. A, C, D: These staff have immunity via prior infection or vaccination.