Nokea
The nurse is monitoring a client who has received antidysrhythmic therapy for the treatment of premature ventricular contractions (PVCs). Which observation in the PVCs would indicate to the nurse that this therapy is ineffective?
- A. Occur in pairs
- B. Be unifocal in appearance
- C. Be fewer than 6 per minute
- D. Fall after the end of the T wave
Correct Answer: A
Rationale: PVCs are considered dangerous when they are frequent (more than 6 per minute), occur in pairs or couplets, are multifocal (multiform), or fall on the T wave.
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Which of the following patient care tasks is coupled with the appropriate member of the nursing care team in terms of their legal scope of practice?
- A. An unlicensed staff member who has been 'certified' by the employing agency to monitor telemetry: Monitoring cardiac telemetry
- B. An unlicensed assistive staff member like a nursing assistant who has been 'certified' by the employing agency to insert a urinary catheter: Inserting a urinary catheter
- C. A licensed practical nurse: The circulating nurse in the perioperative area
- D. A licensed practical nurse: The first assistant in the perioperative area
Correct Answer: A
Rationale: Monitoring cardiac telemetry is within the scope of practice for unlicensed staff who are specifically trained and certified by the employing agency. Inserting a urinary catheter typically requires a higher level of licensure (e.g., LPN or RN), and LPNs are not typically authorized to serve as circulating nurses or first assistants in the perioperative area, as these roles require advanced training or RN licensure.
The nurse is beginning the shift and is assessing the oxygen exchange on a neonate. The nurse reviews the chart for pulse oximetry reading for the last 8 hours. The pulse oximetry reading at 3:30 p.m. is 75%. What should the nurse do first?
- A. Administer oxygen via mask.
- B. Swaddle the neonate in heated blankets.
- C. Reassess the oximetry reading in 30 minutes.
- D. Draw blood gases for oxygen and carbon dioxide levels.
Correct Answer: C
Rationale: A pulse oximetry reading of 75% is concerning but may be due to probe misplacement. Reassessing the reading first confirms accuracy before escalating to invasive measures like blood gases.
A client with Parkinson's disease is prescribed levodopa-carbidopa. Which side effect should the nurse monitor for?
- A. Hypertension.
- B. Dyskinesia.
- C. Hypoglycemia.
- D. Weight gain.
Correct Answer: B
Rationale: Dyskinesia, involuntary movements, is a common side effect of levodopa-carbidopa due to dopamine overstimulation.
Number the priority of the following conditions using the numbers # 1 through # 6 with # 1 as the greatest priority and # 6 as the least priority. 1. Atrial fibrillation 2. First degree heart block 3. Shortness of breath upon exertion 4. An obstructed airway 5. Fluid needs 6. Respect and esteem by others
- A. 3,4,2,1,5,6
- B. 3,4,5,1,2,6
- C. 2,3,5,1,4,6
- D. 3,2,4,1,5,6
Correct Answer: B
Rationale: Using the ABC (Airway, Breathing, Circulation) priority framework and Maslow's hierarchy, the correct order is: An obstructed airway (4, #1, life-threatening), Shortness of breath upon exertion (3, #2, breathing issue), Fluid needs (5, #3, physiological need), Atrial fibrillation (1, #4, potential circulatory issue), First degree heart block (2, #5, often asymptomatic), Respect and esteem by others (6, #6, psychological need). Thus, B (3,4,5,1,2,6) is correct.
The nurse is caring for a client with a chest tube. Which observation indicates a potential complication?
- A. Continuous bubbling in the water seal chamber
- B. Tidaling in the water seal chamber
- C. Drainage of 50 mL/hour
- D. Secured dressings around the tube site
Correct Answer: A
Rationale: Continuous bubbling in the water seal chamber suggests an air leak, a potential complication requiring immediate investigation.