Nokea
The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first?
- A. Perform defibrillation
- B. Administer epinephrine as ordered
- C. Assess for presence of pulse
- D. Institute CPR
Correct Answer: C
Rationale: Assess for presence of pulse. Verifying the absence of a pulse confirms ventricular fibrillation before proceeding with treatment.
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An elderly client who has just had a prosthetic hip implant.
The nurse should position the client
- A. with the affected hip internally rotated and flexed.
- B. with the affected hip adducted when turned.
- C. in the supine position with the knees elevated 90°.
- D. side-lying with the affected hip in a position of abduction.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) flexion beyond 60°, adduction and internal rotation should be avoided in the early postoperative period (2) flexion beyond 60°, adduction and internal rotation should be avoided in the early postoperative period (3) flexion beyond 60°, adduction and internal rotation should be avoided in the early postoperative period (4) correct-position of abduction should be maintained
A client who is terminally ill has been receiving high doses of an opioid analgesic for the past month. As death approaches and the client becomes unresponsive to verbal stimuli, what orders would the nurse expect from the health care provider?
- A. Decrease the analgesic dosage by half
- B. Discontinue the analgesic
- C. Continue the same analgesic dosage
- D. Prescribe a less potent drug
Correct Answer: C
Rationale: Continue the same analgesic dosage. Dying patients who have been in chronic pain will probably continue to experience pain even though they cannot communicate their experience. Pain medication should be continued at the same dose, if effective.
A client has been brought into the emergency room for treatment of a suspected drug overdose. The client appears to be highly agitated, fearful, and may be hallucinating.
The nurse should anticipate the client's need for
- A. immediate support from family and friends who accompanied her.
- B. a warm, friendly approach to reduce fears.
- C. a quiet, darkened room to decrease sensory stimulation.
- D. an immediate referral to a social service agency.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) inappropriate at this time because the client is not in contact with reality (2) may agitate the client further (3) correct-sensory stimulation would only increase agitation and could potentially lead to aggressive behavior and injury (4) not the priority at this time
A Hispanic client refuses emergency room treatment until a curandero is called. The nurse understands that this person brings what to situations of illness?
- A. Holistic healing
- B. Spiritual advising
- C. Herbal preparations
- D. Witchcraft potions
Correct Answer: A
Rationale: Holistic healing. This traditional folk practitioner uses holistic methods for illnesses, often working with traditional health care providers.
The nurse is caring for a client who had a myocardial infarction yesterday and received alteplase (tPA). The client's spouse asks the nurse why that medication was given. What should the nurse include when replying?
- A. Alteplase (tPA) is given to relieve the pain of a heart attack.
- B. Alteplase (tPA) dissolves the clot that is blocking a coronary artery.
- C. Alteplase (tPA) prevents new clots from forming and existing clots from getting bigger.
- D. Alteplase (tPA) helps the heart muscle to repair itself.
Correct Answer: B
Rationale: Alteplase (tPA) is a thrombolytic drug and dissolves the clot that is blocking a coronary artery. It does not relieve pain, prevent new clots from forming, or help the heart muscle to heal.