Nokea
The nurse is caring for a client with weak pedal pulses, absent hair on bilateral legs, and a full-thickness wound on the right lateral malleolus with defined margins, including a minimal amount of serous exudate. Which of the following interventions is contraindicated?
- A. Apply TED hose to bilateral legs
- B. Assess the need for smoking cessation
- C. Physical therapy consult
- D. Obtain Ankle-Brachial Index (ABI) with a hand-held Doppler
Correct Answer: A
Rationale: TED hose are contraindicated in arterial insufficiency (indicated by weak pulses and hair loss), as they may worsen ischemia.
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Which of the following teaching topics should the nurse prioritize when educating staff about caring for a client with a pacemaker? Select all that apply.
- A. Understanding the indications for pacemaker placement.
- B. Recognizing signs of pacemaker malfunction.
- C. Explaining different types of pacemakers and how they function.
- D. Advising clients with pacemakers to avoid all sources of electromagnetic fields (EMFs).
- E. Discussing the importance of regular pacemaker check-ups and follow-up care.
- F. Providing guidelines on safe physical activities and exercise after pacemaker placement
Correct Answer: A,B,C,E,F
Rationale: Understanding indications helps staff anticipate client needs. Recognizing malfunction signs ensures timely intervention. C: Correct - Knowing pacemaker types aids in proper care. D: Incorrect - Avoiding all EMFs is overly restrictive; modern pacemakers are shielded. E: Correct - Regular check-ups ensure device functionality. F: Correct - Safe activity guidelines prevent complications.
Which of the following statements should the nurse include when teaching a community health course on adult cardiopulmonary resuscitation (CPR)? Select all that apply.
- A. The compression rate is 100 to 120 per minute.
- B. The compression depth should be 1.5 inches.
- C. Allow full chest recoil between compressions.
- D. Rotate compressor at least every 2 minutes.
- E. Stop to check your pulse every 30 seconds.
Correct Answer: A,C,D
Rationale: Compression rate of 100-120/min ensures adequate circulation. B: Incorrect - Depth should be 2-2.4 inches in adults. C: Correct - Full chest recoil maximizes venous return. D: Correct - Rotating compressors prevents fatigue. E: Incorrect - Pulse checks are done after rhythm checks, not every 30 seconds.
The nurse is caring for a client with the following tracing on the electrocardiogram (ECG). The nurse identifies this tracing as
- A. sinus tachycardia.
- B. supraventricular tachycardia.
- C. ventricular tachycardia.
- D. atrial flutter.
Correct Answer: C
Rationale: Ventricular tachycardia is a life-threatening arrhythmia requiring immediate intervention, characterized by wide QRS complexes on ECG.
The nurse is caring for a client with the following tracing on the electrocardiogram (ECG). The nurse should anticipate a prescription for which medication? See the image below.
- A. Adenosine
- B. Atropine
- C. Labetalol
- D. Amiodarone
Correct Answer: D
Rationale: Amiodarone is used for ventricular arrhythmias (e.g., ventricular tachycardia), which may be indicated by the ECG.
The nurse has instructed a client who is scheduled to have a carotid ultrasound. Which of the following statements by the client would require follow up?
- A. I plan to eat a light meal before the ultrasound.
- B. I will remove any jewelry or metal objects from my neck before the procedure.
- C. I understand that the ultrasound will use sound waves to create images of my carotid arteries.
- D. I should fast for at least 8 hours before the ultrasound.
Correct Answer: D
Rationale: Carotid ultrasound does not require fasting, so this statement requires correction.