Nokea
The nurse is observing continuous cardiac monitoring for assigned clients. Which of the following cardiac rhythms would immediate follow-up?
Correct Answer: C
Rationale: Ventricular fibrillation (VF) is a lethal dyshythmia characterized by disorganized electrical activity in the heart ventricles. Because
of this erratic electrical activity, the heart muscles lose the ability to contract, resulting in loss of blood flow and pulse (ie, cardiac
arrest). Nurses who identify a client with VF should immediately check the pulse, start CPR, and prepare the client for defibrillation
You may also like to solve these questions
The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules. The client states 'I cannot take the medication in this form.' What is the nurse's first action?
- A. Ask the health care provider to prescribe a different calcium channel blocker
- B. Consult with the pharmacist to see if an alternate form of the drug is available
- C. Open the capsule and sprinkle the medication in a cup of applesauce
- D. Warn the client about the dangers of uncontrolled hypertension
Correct Answer: B
Rationale: The client may object to gelatin in capsules due to dietary restrictions. Consulting the pharmacist for an alternative form respects the client's beliefs.
Triazolam (Halcion) 0.25 mg is ordered for a client at bedtime. When the nurse goes to give the medication, the client asks the nurse to leave it at the bedside because she wants to finish reading a book. What is the best action for the nurse to take?
- A. Leave the medication at the bedside as requested
- B. Return in one hour and offer the medication again
- C. Tell the client to call when she is ready for the medication
- D. Explain to the client that this is the time medications are given and she should take it now
Correct Answer: B
Rationale: Returning in an hour ensures medication administration while respecting the client's request, adhering to safety protocols. Leaving medication or delaying indefinitely risks errors.
The nurse is caring for a 2 month-old infant with a congenital heart defect. Which of the following is a priority nursing action?
- A. Provide small feedings every 3 hours
- B. Maintain intravenous fluids
- C. Add strained cereal to the diet
- D. Change to reduced calorie formula
Correct Answer: A
Rationale: Infants with congenital heart defects are at increased risk for developing congestive heart failure. Infants with congestive heart failure have an increased metabolic rate and require additional calories to grow. At the same time, however, rest and conservation of energy for eating is important. Feedings should be smaller and every 3 hours rather than the usual 4 hour schedule.
The nurse is caring for a client with major depressive disorder. Which of the following findings would be consistent with the condition?
- A. hypervigilance and intrusive memories
- B. impulsivity and intense fear of abandonment
- C. changes in appetite and personal hygiene
- D. extreme shyness and hypersensitivity to criticism
Correct Answer: C
Rationale: Major depressive disorder is characterized by symptoms such as changes in appetite, sleep disturbances, and neglect of personal hygiene due to low energy and motivation.
A nurse has administered several blood transfusions over 3 days to a 12 year-old client with Thalassemia. What lab value should the nurse monitor closely during this therapy?
- A. Hemoglobin
- B. Red Blood Cell Indices
- C. Platelet count
- D. Neutrophil percent
Correct Answer: A
Rationale: Hemoglobin should be in a therapeutic range of approximately 10 g/dl (100 g). This level is low enough to foster the patient’s own erythropoiesis without enlarging the spleen.