Nokea
The nurse is caring for a client receiving a prescribed diltiazem infusion. The client has the following tracing on the electrocardiogram shown in the exhibit. The nurse should perform which priority action? See the exhibit for additional client information.
- A. pause the diltiazem infusion.
- B. notify the primary healthcare physician (PHCP).
- C. assess the client's oxygen saturation and respiratory rate (RR).
- D. prepare a prescription of intravenous (IV) atropine
Correct Answer: A
Rationale: The tracing shows sinus bradycardia. The priority action would be to pause the diltiazem infusion, as this medication is a calcium channel blocker that lowers heart rate and blood pressure. If the infusion continued, it would lower the heart rate to dangerous levels, compromising cardiac output. Once paused, the nurse should contact the primary healthcare provider.
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The nurse is caring for a group of preoperative clients. Which client situation requires follow-up? A client, Select all that apply.
- A. stating that they took their prescribed carbamazepine with a sip of water.
- B. receiving dextrose 5% in water (D5W) and has a blood glucose of 266 mg/dL (14.77 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L].
- C. reporting that they shaved their abdomen for their scheduled appendectomy.
- D. reporting difficulty with their last surgery, stating they got 'a really high fever'.
- E. reporting burning upon urination and increased urinary frequency.
Correct Answer: B, C, D, E
Rationale: High blood glucose (B) risks surgical complications, shaving abdomen (C) increases infection risk, past surgical fever (D) suggests complications, and urinary symptoms (E) indicate possible UTI, all needing follow-up. Carbamazepine with water (A) is typically acceptable pre-op.
The nurse is caring for assigned clients. The nurse should immediately follow-up on the client who
- A. is being treated for pneumonia and develops restlessness.
- B. is receiving intravenous fluids for influenza and dehydration and reports a headache.
- C. has a chest drainage system in place for a hemothorax and tidaling is present in the water seal chamber.
- D. is being treated for pleurisy and is experiencing inspiratory chest pressure.
Correct Answer: A
Rationale: Restlessness in pneumonia (A) may indicate hypoxia, requiring immediate follow-up. Headache with fluids (B), tidaling in chest tube (C), and pleurisy pain (D) are expected or less urgent.
A licensed practical/vocational (LPN/VN) nurse assists the behavioral health unit's registered nurse (RN). Which task can the RN appropriately delegate to the LPN/VN?
- A. Alcohol withdrawal screening on a client going through detoxification
- B. Medication administration to a client with a nasogastric tube
- C. Suicide assessment on a newly admitted client
- D. Educating a client on newly prescribed citalopram
Correct Answer: B
Rationale: Medication administration via nasogastric tube (B) is within the LPN’s scope. Alcohol withdrawal screening (A), suicide assessment (C), and education on new medications (D) require RN-level assessment and teaching skills.
The nurse is caring for a client with a percutaneous endoscopic gastrostomy tube. Prior to administering the next tube feeding, the nurse aspirates 80 mL of gastric residual. The nurse should then
- A. notify the physician.
- B. hold the tube feeding and recheck residual volume in one hour.
- C. administer the prescribed feeding.
- D. reposition the patient in low-Fowler's position.
Correct Answer: B
Rationale: An 80 mL gastric residual (B) indicates potential delayed gastric emptying, requiring the nurse to hold the feeding and recheck in one hour to prevent aspiration. Notifying the physician (A) is premature, administering feeding (C) risks complications, and low-Fowler’s (D) is inappropriate for feeding.
The nurse in the emergency department is caring for a client who sustained multiple rib fractures and a nasal fracture from a motor vehicle crash. Which assessment finding requires immediate follow-up?
- A. shallow respirations
- B. chest pain with repositioning
- C. bruising on the chest
- D. vomiting
Correct Answer: A
Rationale: Shallow respirations (A) in a client with rib fractures suggest impaired ventilation, risking hypoxia or pneumothorax, requiring immediate follow-up. Chest pain (B), bruising (C), and vomiting (D) are expected but less urgent.