Nokea
The nurse is teaching a client with asthma about the use of a peak flow meter. Which of the following instructions should be included?
- A. Use the meter only when symptoms are present.
- B. Record the highest of three readings.
- C. Clean the meter with soap and water weekly.
- D. Blow into the meter as slowly as possible.
Correct Answer: B, C
Rationale: Recording the highest of three readings ensures accuracy, and cleaning the meter weekly prevents contamination.
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A client is receiving a continuous infusion of heparin. The nurse notes a partial thromboplastin time (PTT) of 120 seconds. What should the nurse do first?
- A. Stop the infusion
- B. Reduce the infusion rate
- C. Administer protamine sulfate
- D. Notify the physician
Correct Answer: A
Rationale: A PTT of 120 seconds is significantly above the therapeutic range (1.5 to 2 times normal), indicating a risk of bleeding. Stopping the infusion is the first action to prevent harm.
For which of the following should the nurse be especially alert when caring for a term neonate, who weighed 10 lb at birth, 1 hour after a vaginal delivery?
- A. Hypoglycemia.
- B. Hypercalcemia.
- C. Hypermagnesemia.
- D. Hyperbilirubinemia.
Correct Answer: A
Rationale: The neonate would be considered large for gestational age (LGA) because the neonate weighs more than 4,000 g (90th percentile). Hypoglycemia is a problem for the LGA neonate because glycogen stores are quickly used to maintain the weight. Other complications like hyperbilirubinemia may occur, but hypoglycemia is the priority concern within the first hour.
The nurse is assessing a client with suspected hyperthyroidism. Which of the following symptoms is most likely to be present?
- A. Weight gain.
- B. Cold intolerance.
- C. Tremors.
- D. Constipation.
Correct Answer: C
Rationale: Tremors are a common symptom of hyperthyroidism due to increased metabolic rate and nervous system stimulation.
The nurse is preparing to assess a client admitted with a diagnosis of trigeminal neuralgia (tic douloureux). On review of the client's record, which symptom should the nurse expect the client is experiencing?
- A. Bilateral pain in the area of the sixth cranial nerve
- B. Unilateral pain in the area of the sixth cranial nerve
- C. Abrupt onset of pain in the area of the fifth cranial nerve
- D. Chronic, intermittent pain in the area of the seventh cranial nerve
Correct Answer: C
Rationale: Trigeminal neuralgia is a chronic syndrome characterized by an abrupt onset of pain. It involves one or more divisions of the trigeminal nerve (cranial nerve V). The remaining options are incorrect.
Identify this cardiac rhythm strip. Fill in the blank. A. Third Degree Heart Block B. Second-Degree Atrioventricular Block, Type II C. Ventricular fibrillation D. Premature Atrial Contractions
- B. Third Degree Heart Block
- C. Second-Degree Atrioventricular Block, Type II
- D. Ventricular fibrillation
- E. Premature Atrial Contractions
Correct Answer: A
Rationale: Third Degree Heart Block shows complete dissociation between P waves and QRS complexes, assuming the strip matches this description.