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The nurse is caring for clients on a medical floor. Which client is most likely to experience sudden cardiac death?
- A. The 84-year-old client exhibiting uncontrolled atrial fibrillation.
- B. The 60-year-old client exhibiting asymptomatic sinus bradycardia.
- C. The 53-year-old client exhibiting ventricular fibrillation.
- D. The 65-year-old client exhibiting supraventricular tachycardia.
Correct Answer: C
Rationale: Ventricular fibrillation is a lethal arrhythmia causing sudden cardiac death if untreated. Atrial fibrillation, bradycardia, and SVT are less immediately fatal.
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The ED nurse is caring for a client diagnosed with frostbite of the feet. Which intervention should the nurse implement?
- A. Massage the feet vigorously.
- B. Soak the feet in warm water.
- C. Apply a heating pad to feet.
- D. Apply petroleum jelly to feet.
Correct Answer: B
Rationale: Soaking in warm water (40–42°C) gradually rewarms frostbitten tissue, preventing damage. Massage risks tissue injury, heating pads cause burns, and petroleum jelly is ineffective.
The client diagnosed with septicemia has the following health-care provider orders. Which HCP order has the highest priority?
- A. Provide clear liquid diet.
- B. Initiate IV antibiotic therapy.
- C. Obtain a STAT chest x-ray.
- D. Perform hourly glucometer checks.
Correct Answer: B
Rationale: IV antibiotics are critical in septicemia to combat infection, the primary cause. Diet, x-ray, and glucose checks are secondary to infection control.
The elderly client is brought to the ED complaining of cramps, headache, and weakness after working outside in the sun. The telemetry shows sinus tachycardia. Which intervention should the nurse implement?
- A. Determine if the client is experiencing any thirst.
- B. Administer D5W intravenously at 250 mL/hr.
- C. Maintain a cool environment to promote rest.
- D. Withhold the client’s oral intake.
Correct Answer: C
Rationale: Heat exhaustion (suggested by symptoms) requires a cool environment to reduce core temperature. Thirst assessment, D5W, and withholding intake are secondary or incorrect.
The nurse working in an outpatient clinic is caring for a client who is experiencing epistaxis. Which intervention should the nurse implement first?
- A. Take the client’s blood pressure in both arms.
- B. Hold the nose with thumb and finger for 15 minutes.
- C. Have the client sit with the head tilted back and hold a tissue.
- D. Prepare to administer silver nitrate, a cauterizing agent, with a packing applicator.
Correct Answer: B
Rationale: Holding the nose for 15 minutes stops bleeding, the first intervention for epistaxis. BP, head tilting back (risks aspiration), and cauterization are secondary.
The triage nurse is working in the emergency department. Which client should be assessed first?
- A. The 10-year-old child whose dad thinks the child’s leg is broken.
- B. The 45-year-old male who is diaphoretic and clutching his chest.
- C. The 58-year-old female complaining of a headache and seeing spots.
- D. The 25-year-old male who cut his hand with a hunting knife.
Correct Answer: B
Rationale: Chest pain with diaphoresis suggests acute myocardial infarction, a life-threatening emergency requiring immediate assessment. Fractures, headaches, and cuts are less urgent.