Nokea
The nurse is caring for a client who is experiencing the cardiac rhythm shown in the ECG strip below. The nurse should recognize that the client is experiencing
- A. atrial fibrillation
- B. ventricular fibrillation
- C. sinus bradycardia
- D. normal sinus rhythm
Correct Answer: B
Rationale: Ventricular fibrillation is a life-threatening arrhythmia requiring immediate intervention. Atrial fibrillation , sinus bradycardia , and normal rhythm are less urgent.
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Propranolol is prescribed for an adult suspected to have Graves' disease. The nurse explains to the client that propranolol is prescribed for which purpose?
- A. To decrease the activity of the thyroid gland
- B. To provide the hormone the client is missing
- C. To regulate the client's metabolism
- D. To slow the heart rate
Correct Answer: D
Rationale: Propranolol, a beta-blocker, slows heart rate, controlling tachycardia in Graves' disease (hyperthyroidism). It does not affect thyroid activity, provide hormones, or regulate metabolism.
What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero?
- A. The disease will incubate longer and progress more slowly in this infant
- B. The infant is very susceptible to infections
- C. Growth and development patterns will proceed at a normal rate
- D. Careful monitoring of renal function is indicated
Correct Answer: B
Rationale: The infant is very susceptible to infections. HIV compromises the immune system, increasing susceptibility to opportunistic infections.
Laboratory reference ranges
Hematocrit
39%-59%
(0.39-0.59)
The nurse is collecting data from a 2-week-old client who has tetralogy of Fallot. Which of the following findings would be a priority to follow up?
- A. cyanosis resolves in the knee-chest position
- B. weight gain of 0.6 lb (0.27 kg) since birth
- C. hematocrit level of 67% (0.67)
- D. murmur noted on auscultation
Correct Answer: C
Rationale: Elevated hematocrit indicates polycythemia, a serious complication of tetralogy of Fallot. Knee-chest relief , weight gain , and murmurs are expected.
The nurse is preparing to administer a scheduled dose of metoclopramide IV to a client with diabetic gastroparesis. Which clinical finding causes the nurse to question the prescription?
- A. Diarrhea
- B. Frequent burping
- C. Headache
- D. Sucking lip motions
Correct Answer: D
Rationale: Sucking lip motions suggest tardive dyskinesia, a contraindication for metoclopramide due to risk of worsening. Diarrhea , burping , and headache are not contraindications.
Because a client is scheduled for a liver biopsy, the nurse should check to be sure that which laboratory test results have been received?
- A. Serum electrolytes
- B. Prothrombin time
- C. CBC with differential
- D. Serum creatinine
Correct Answer: B
Rationale: Liver biopsy carries a risk of bleeding due to the liver's vascular nature. Prothrombin time assesses clotting ability, critical to ensure the client can safely undergo the procedure without excessive bleeding risk. Electrolytes, CBC, and creatinine are less directly related to bleeding risk.