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 practical nurse is reinforcing discharge teaching to a client seen for treatment of a second episode of acute gout. Which instructions should be included to prevent future exacerbations? Select all that apply.
- A. Achieve and maintain a healthy weight
- B. Avoid diet sodas
- C. Avoid foods containing protein
- D. Drink plenty of fluids
- E. Restrict alcohol consumption
Correct Answer: A,D,E
Rationale: Healthy weight (A), hydration (D), and limiting alcohol (E) reduce uric acid levels and gout risk. Diet sodas (B) are not directly linked, and avoiding all protein (C) is unnecessary.
Phototherapy is ordered for a newborn with physiologic jaundice. The nurse caring for the infant should:
- A. Offer the baby sterile water between feedings of formula
- B. Apply an emollient to the baby's skin to prevent drying
- C. Wear a gown, gloves, and a mask while caring for the infant
- D. Place the baby on enteric isolation
Correct Answer: B
Rationale: Applying an emollient prevents skin drying, a common issue during phototherapy due to exposure to light.
The family of a 90-year-old resident in a long-term care facility asks the nurse why the client only gets a shower three times a week. What information is most important for the nurse to include when answering the question?
- A. The staff members have limited time and must schedule all the residents.
- B. The client's skin is dry; too many showers will dry the skin further.
- C. The client has limited energy and must conserve it.
- D. The client is not very active and doesn't get very dirty.
Correct Answer: B
Rationale: Frequent showers can exacerbate dry skin in elderly clients, increasing irritation or breakdown risk. Staffing, energy, or activity levels are less relevant to skin health.
An 80-year-old client is prescribed codeine for a severe cough. The home health nurse is reinforcing instructions on how to prevent the common adverse effects associated with codeine. Which client statements indicate an understanding of how to prevent them? Select all that apply.
- A. I'll be sure to apply sunscreen if I go outside.
- B. I'll drink at least 8 glasses of water a day.
- C. I'll drink decaffeinated coffee so I can sleep at night.
- D. I'll sit on the side of my bed for a few minutes before getting up.
- E. I'll take my medicine with food.
Correct Answer: B,D,E
Rationale: Drinking water (B) prevents constipation, sitting before standing (D) avoids orthostatic hypotension, and taking with food (E) reduces nausea. Sunscreen (A) and decaf coffee (C) are unrelated to codeine effects.
The nurse is talking with a client who has a new prescription for misoprostol to prevent gastric ulcers. Which of the following statements by the client would require follow-up?
- A. I will take this medication with meals and at bedtime.
- B. I plan to use a reliable form of birth control while taking this medication.
- C. I can take this medication with an antacid to prevent an upset stomach.
- D. I should notify my health care provider if I develop black, tarry stools while taking this medication.
Correct Answer: C
Rationale: Taking misoprostol with antacids (C) reduces its efficacy and requires follow-up. Taking with meals (A), using contraception (B), and reporting black stools (D) are correct.