Nokea
The nurse is caring for a client who goes into ventricular tachycardia. Which intervention should the nurse implement first?
- A. Call a code immediately.
- B. Assess the client for a pulse.
- C. Begin chest compressions.
- D. Continue to monitor the client.
Correct Answer: B
Rationale: Ventricular tachycardia requires assessing for a pulse (B) to determine if it’s pulseless (needing CPR, C) or stable (medication). Calling a code (A) or monitoring (D) depends on pulse status.
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The nurse counts an adult's apical heart beat at 110 beats per minute. The nurse describes this as:
- A. asystole.
- B. bigeminy.
- C. tachycardia.
- D. bradycardia.
Correct Answer: C
Rationale: Tachycardia in an adult is defined as a heart rate above 100 beats per minute. Asystole is cardiac arrest with no heartbeat. Bigeminy refers to heartbeats occurring in pairs. Bradycardia is a heart rate of 60 beats or less per minute.
Which assessment finding documented by the nurse provides the best evidence that the client has a bacterial infection?
- A. Chest pain
- B. Dry cough
- C. Fever
- D. Dyspnea
Correct Answer: C
Rationale: Fever is a hallmark of bacterial infection, such as in endocarditis.
An adult client is admitted with a diagnosis of left-sided congestive heart failure. Which assessment finding would most likely be present?
- A. Distended neck veins
- B. Dyspnea
- C. Hepatomegaly
- D. Pitting edema
Correct Answer: B
Rationale: Dyspnea is a hallmark symptom of left-sided congestive heart failure due to pulmonary congestion. Distended neck veins, hepatomegaly, and pitting edema are more associated with right-sided heart failure.
Before administering the digoxin (Lanoxin) to the client, what nursing assessment is essential?
- A. The client's heart rate
- B. The client's blood pressure
- C. The client's heart sounds
- D. The client's breath sounds
Correct Answer: A
Rationale: Check heart rate; withhold digoxin if <60 bpm to prevent toxicity.
The nurse informs the client that the correct way to administer nitroglycerin is to place one tablet where?
- A. The nurse is the first and check
- B. At the back of the throat
- C. Under the tongue
- D. Between the teeth
Correct Answer: C
Rationale: Sublingual nitroglycerin is placed under the tongue for rapid absorption into the bloodstream to relieve angina.