Nokea
The nurse is caring for a client in critical condition requiring several medications. The nurse understands which route of administration would be recommended for this client?
- A. Subcutaneous (subQ)
- B. Intravenous (IV)
- C. Intramuscular (IM)
- D. Oral (PO)
Correct Answer: B
Rationale: IV administration provides rapid and reliable delivery for a client in critical condition.
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The nurse is caring for a client with Meniere's Disease. Which of the following assessment findings would be expected? Select all that apply.
- A. Presbyopia
- B. Tinnitus
- C. Vertigo
- D. Dyskinesia
- E. Hearing loss
Correct Answer: B,C,E
Rationale: Meniere's disease is characterized by tinnitus (ringing in the ears), vertigo (spinning sensation), and hearing loss due to inner ear dysfunction. Presbyopia (age-related vision loss) and dyskinesia (abnormal movements) are not associated with Meniere's disease.
The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a new systolic murmur at the apex. The nurse should first:
- A. Assess for changes in vital signs.
- B. Draw an arterial blood gas.
- C. Evaluate heart sounds with the client leaning forward.
- D. Obtain a 12 Lead electrocardiogram.
Correct Answer: A
Rationale: A new systolic murmur post-myocardial infarction may indicate complications like ventricular septal rupture or mitral regurgitation. Assessing vital signs first helps determine the client's stability and guides further actions.
What is the nurse's priority for a client with an altered level of consciousness?
- A. Assess airway.
- B. Check reflexes.
- C. Monitor urine output.
- D. Perform a pain assessment.
Correct Answer: A
Rationale: Assessing the airway is the priority to ensure adequate oxygenation in a client with altered consciousness.
While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an I.V. infusion of 5% dextrose in water (D5W) and oxygen at 2 L/minute. The nurse's first course of action should be:
- A. Increase the I.V. infusion rate.
- B. Notify the physician promptly.
- C. Increase the oxygen concentration.
- D. Administer a prescribed analgesic.
Correct Answer: B
Rationale: Frequent PVCs (eight per minute) may indicate irritability of the myocardium, risking serious arrhythmias. Notifying the physician promptly ensures timely intervention, such as antiarrhythmic therapy.
The nurse provides discharge instructions to a client diagnosed with bacterial conjunctivitis. Which of the following statements by the client would indicate effective understanding? Select all that apply.
- A. It is okay for me to wear my contact lenses during this infection.'
- B. Swimming during this infection is allowed.'
- C. I should not share my towels with family members.'
- D. To prevent injury, I should not rub my eye.'
- E. I should wash my hands frequently.'
Correct Answer: C,D,E
Rationale: Bacterial conjunctivitis requires avoiding contact lenses and swimming to prevent worsening or spreading infection, not sharing towels, avoiding eye rubbing to prevent corneal damage, and frequent hand washing to reduce transmission.