Nokea
The nurse is caring for a client who is experiencing the cardiac rhythm in the ECG strip shown below. The nurse should recognize that the client is experiencing
- A. atrial flutter
- B. sinus bradycardia
- C. normal sinus rhythm
- D. premature atrial contractions
Correct Answer: C
Rationale: Without the ECG strip, normal sinus rhythm (C) is assumed for a stable client, characterized by regular P waves, QRS complexes, and a rate of 60-100 bpm. Other options indicate abnormal rhythms.
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The nurse is reinforcing teaching for a client with suspected Cushing syndrome who has a 24-hour urine specimen. Which of the following information should the nurse reinforce? Select all that apply.
- A. An indwelling urinary catheter will be inserted for this test and your urine will be collected in an attached drainage bag.
- B. Discard your first void in the toilet and then record the start time of the urine collection so that the start time coincides with an empty bladder.
- C. Keep the collection container in the refrigerator or a cooled ice chest when it is not in use.
- D. Only daytime urine should be collected in the container because cortisol levels are higher in the morning.
- E. You will be given an opaque plastic container to collect your urine to protect it from light.
Correct Answer: B,C
Rationale: Discarding the first void and recording the start time (B) ensures accurate collection, and refrigerating the container (C) preserves the sample. Catheters (A) are not needed, all urine is collected (D is incorrect), and light protection (E) is unnecessary.
The nurse is preparing to administer a scheduled vaccine to a pediatric client with hemophilia. Which of the following actions should the nurse take? Select all that apply.
- A. Administer ibuprofen for pain relief.
- B. Apply a warm compress to the injection site.
- C. Hold firm pressure to the injection site for 5 minutes.
- D. Massage the injection site to disperse the medication.
- E. Use the smallest bore and shortest needle length indicated.
Correct Answer: C,E
Rationale: Firm pressure for 5 minutes (C) and using a small, short needle (E) minimize bleeding in hemophilia. Ibuprofen (A) increases bleeding risk, warm compresses (B) may worsen bleeding, and massage (D) can cause hematoma.
A client with acquired immunodeficiency syndrome is admitted for treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract?
- A. Thoroughly cooking all foods
- B. Offering yogurt and buttermilk between meals
- C. Forcing fluids
- D. Providing small, frequent meals
Correct Answer: D
Rationale: Small, frequent meals are easier to digest and absorb, compensating for the limited absorptive capacity in wasting syndrome. Cooking foods thoroughly reduces infection risk but doesn't aid absorption. Yogurt and buttermilk may not be tolerated, and forcing fluids addresses hydration, not absorption.
The nurse is caring for a client who has bleeding esophageal varices. What should the nurse expect might develop in this client? Select all that apply.
- A. Confusion
- B. Tarry stools
- C. Lower abdominal pain and pressure
- D. High blood pressure
- E. Tremors
- F. Hallucinations
Correct Answer: A,B
Rationale: Bleeding varices cause blood loss, leading to tarry stools (melena) from digested blood and confusion from hepatic encephalopathy due to liver dysfunction. Abdominal pain, hypertension, tremors, or hallucinations are less directly related.
A client with cancer has been placed on TPN. The nurse notes air entering the client via the central line. Which initial action is most appropriate?
- A. Notify the physician.
- B. Elevate the head of the bed.
- C. Place the client in the left lateral decubitus position.
- D. Stop the TPN and hang D51/2 NS.
Correct Answer: C
Rationale: The client is at risk for an air embolus. Placing the client in this position displaces air away from the right ventricle. Answers B and D would not help, so they are incorrect, and answer A would not be done first, so it's incorrect.