Nokea
The nurse is monitoring a client's cardiac rhythm when an abnormal rhythm occurs. Which of the following cardiac rhythms does the ECG strip (see image) indicate?
- A. Ventricular fibrillation
- B. Ventricular tachycardia
- C. Atrial fibrillation
- D. Atrial flutter
Correct Answer: B
Rationale: Without the ECG strip, ventricular tachycardia (B) is a common abnormal rhythm requiring urgent intervention, characterized by wide QRS complexes. Other rhythms (A, C, D) have distinct patterns.
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The nurse is caring for a client with a stage II sacral ulcer. Which nursing intervention would be most effective in promoting healing?
- A. a heat lamp positioned 12 inches from the skin for 10 minutes twice a day
- B. antibiotic therapy as ordered
- C. increasing the client's nutritional intake of protein and calories
- D. wet to dry dressings once every shift
Correct Answer: C
Rationale: Increased protein and calorie intake supports tissue repair and healing for a stage II ulcer, more than heat lamps, antibiotics (unless infection is present), or wet-to-dry dressings.
The nurse prepares a 25-year-old woman for a cesarean section. The patient says she had major surgery several years ago and asks if she will receive a similar 'shot' before surgery. The nurse’s response should be based on an understanding that the preoperative medication given before a cesarean section
- A. contains a lower overall dosage of medication than is given before general surgery.
- B. contains reduced amounts of sedatives and hypnotics than are given before general surgery.
- C. contains reduced amounts of narcotics than are given before general surgery.
- D. contains medications similar in type and dosages to those given before general surgery.
Correct Answer: C
Rationale: decreased so less narcotic crosses the placental barrier causing respiratory depression in the infant
Which client is at risk for opportunistic diseases such as pneumocystis pneumonia?
- A. The client with cancer who is being treated with chemotherapy
- B. The client with Type I diabetes
- C. The client with thyroid disease
- D. The client with Addison's disease
Correct Answer: A
Rationale: Chemotherapy suppresses the immune system, increasing the risk of opportunistic infections like pneumocystis pneumonia.
In caring for a critically ill client with a nasogastric tube (NGT) for enteral feeding, which action by the nurse demonstrates competency in NGT care? Select all that apply.
- A. The nurse checks gastric residual every 4 hours for continuous feedings.
- B. The nurse maintains the client in a low Fowler's position during feeding.
- C. The nurse checks gastric residual before each bolus or intermittent feeding.
- D. The tubing is changed every 48 hours or when the bag appears visibly soiled.
- E. The nurse returns the residual to the stomach unless the volume is greater than 250 mL.
Correct Answer: A, C, E
Rationale: Checking residuals for continuous and bolus feedings and returning residuals (unless >250 mL) are standard. Low Fowler’s increases aspiration risk, and tubing change frequency varies by policy.
A client's serum sodium level is 113 mEq/L. The nurse would expect which findings upon assessment?
- A. headache, confusion, muscle weakness, fatigue
- B. hypertension, muscle cramps, respiratory depression
- C. cardiac arrhythmia, tetany, tachycardia
- D. confusion, nystagmus, tetany, hallucinations
Correct Answer: A
Rationale: Severe hyponatremia (113 mEq/L) causes neurological symptoms like headache, confusion, muscle weakness, and fatigue due to cerebral edema.