Nokea
The nurse is caring for a client with a complete heart block. The nurse should question which of the following orders?
- A. Administer lidocaine (Xylocaine) 50 mg IV push for PVCs in excess of six per minute.
- B. Administer atropine sulfate (Atropine) 0.05 mg IV for symptomatic bradycardia.
- C. Anticipate scheduling the client for a temporary pacemaker if the pulse continues to decrease.
- D. Mix 10 cc of 1:5,000 solution of isoproterenol (Isuprel) in 500 cc D5W for sustained bradycardia below 30.
Correct Answer: A
Rationale: Lidocaine suppresses ventricular activity, which could worsen complete heart block by reducing the ventricular escape rhythm. Options B, C, and D are appropriate: atropine increases heart rate, pacemakers treat persistent bradycardia, and isoproterenol supports severe bradycardia.
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The nurse is caring for an adult who has had nausea and vomiting for several days and is being admitted to the nursing care unit. The client can follow directions. IV fluids were started in the emergency department. Which action is the highest priority for the nurse at this time?
- A. Offer oral fluids every hour.
- B. Turn every two hours.
- C. Monitor urine output.
- D. Put client in a supine position.
Correct Answer: C
Rationale: Monitoring urine output is critical to assess hydration status and kidney function in a client with prolonged nausea and vomiting, as dehydration is a major risk. IV fluids address dehydration, making oral fluids less urgent, and turning or positioning are secondary.
The nurse in the newborn nursery receives report from the previous shift. Which of the following infants should the nurse see FIRST?
- A. A two-day-old infant, lying quietly alert, heart rate of 185 bpm.
- B. A one-day-old infant, crying, and the anterior fontanel is bulging.
- C. A 12-hour-old infant, held by the mother, respirations 45 and irregular.
- D. A five-hour-old infant, sleeping, hands and feet are blue bilaterally.
Correct Answer: A
Rationale: A heart rate of 185 bpm indicates tachycardia (normal 120–160 bpm), suggesting distress or dehydration, requiring immediate assessment. Options B, C, and D are less urgent or normal.
The nurse is caring for a client with a history of heart failure who is receiving torsemide (Demadex) 20 mg PO daily. Which of the following laboratory results should the nurse report immediately?
- A. Potassium 3.0 mEq/L
- B. Sodium 140 mEq/L
- C. Creatinine 1.2 mg/dL
- D. Glucose 100 mg/dL
Correct Answer: A
Rationale: Hypokalemia (3.0 mEq/L) is a serious torsemide side effect, risking arrhythmias in heart failure. Options B, C, and D are normal.
An adult male had a myocardial infarction six weeks ago. He asks the nurse if it is safe for him to have sex. What should the nurse include when replying?
- A. Taking nitroglycerin before sexual activity is often helpful.
- B. Taking drugs for erectile dysfunction in addition to nitroglycerin is advised.
- C. The client should rest for several hours before engaging in sexual activity.
- D. Sexual activity should be avoided for six months after a heart attack.
Correct Answer: A
Rationale: Nitroglycerin before sexual activity can prevent angina, and sexual activity is generally safe 6 weeks post-MI if the patient is stable.
The nurse is caring for a client with a history of deep vein thrombosis who is receiving warfarin (Coumadin) 5 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. INR of 3.5.
- B. PTT of 40 seconds.
- C. Platelet count of 200,000/mm^3.
- D. Hemoglobin of 13 g/dL.
Correct Answer: A
Rationale: An INR of 3.5 is above the therapeutic range (2.0–3.0) for DVT, increasing bleeding risk, requiring dose adjustment. Options B, C, and D are normal: PTT is unaffected, platelet count 200,000/mm^3 is adequate, and hemoglobin 13 g/dL is normal.