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The nurse is teaching CPR to a class. Which statement best explains the definition of sudden cardiac death?
- A. Cardiac death occurs after being removed from a mechanical ventilator.
- B. Cardiac death is the time the HCP officially declares the client dead.
- C. Cardiac death occurs within one (1) hour of the onset of cardiovascular symptoms.
- D. The death is caused by myocardial ischemia resulting from coronary artery disease.
Correct Answer: C
Rationale: Sudden cardiac death is defined as death within 1 hour of cardiovascular symptoms, often due to arrhythmias. Ventilator removal, declaration time, and ischemia are related but not definitional.
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The client has ingested the remaining amount of a bottle of analgesic medication. The medication comes 500 mg per capsule. Two (2) doses of two (2) capsules each have been used by another member of the family. The bottle originally had 250 capsules. How many mg of medication did the client take?
Correct Answer: 123000
Rationale: Total capsules: 250. Used: 2 doses * 2 capsules = 4 capsules. Remaining: 250 - 4 = 246 capsules. Total mg: 246 * 500 mg = 123,000 mg.
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 nurse is caring for a client in the prodromal phase of radiation exposure. Which signs/symptoms should the nurse assess in the client?
- A. Anemia, leukopenia, and thrombocytopenia.
- B. Sudden fever, chills, and enlarged lymph nodes.
- C. Nausea, vomiting, and diarrhea.
- D. Flaccid paralysis, diplopia, and dysphagia.
Correct Answer: C
Rationale: The prodromal phase of radiation exposure involves nausea, vomiting, and diarrhea due to cellular damage. Hematologic effects occur later, fever suggests infection, and paralysis suggests botulism.
The client has recently experienced a myocardial infarction. Which action by the nurse helps prevent cardiogenic shock?
- A. Monitor the client’s telemetry.
- B. Turn the client every two (2) hours.
- C. Administer oxygen via nasal cannula.
- D. Place the client in the Trendelenburg position.
Correct Answer: C
Rationale: Oxygen administration improves myocardial oxygenation, preventing cardiogenic shock post-MI. Telemetry monitors, turning prevents ulcers, and Trendelenburg is contraindicated.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical unit. Which nursing task cannot be delegated to the UAP?
- A. Obtaining the intake and output on a client diagnosed with food poisoning.
- B. Performing a dressing change on the client with a chemical burn.
- C. Assisting a client who overdosed on morphine to the bedside commode.
- D. Help a client with carbon monoxide poisoning turn, cough, and deep breathe.
Correct Answer: B
Rationale: Dressing changes on chemical burns require assessment and sterile technique, a nursing task. Intake/output, ambulation, and turning are delegable to UAPs.