Nokea
The nurse is working on the cardiac unit with a client scheduled to receive digitalis. The nurse understands that which finding is a contraindication for this medication? Select all that apply.
- A. AV block
- B. atrial flutter
- C. atrial fibrillation
- D. sick sinus syndrome
- E. Wolff-Parkinson-White syndrome
Correct Answer: A,D,E
Rationale: AV block, sick sinus syndrome, and Wolff-Parkinson-White syndrome are contraindications for digitalis due to the risk of worsening conduction abnormalities. Atrial flutter and fibrillation are indications.
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A 5-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on:
- A. Preventing infection
- B. Administering antipyretics
- C. Keeping the skin free of moisture
- D. Limiting oral fluid intake
Correct Answer: A
Rationale: Atopic dermatitis involves inflamed skin prone to infection, so preventing infection through gentle skin care and monitoring is a priority.
The nurse is assisting a client who is to undergo a thoracentesis. Which of the following is the optimal position for the procedure?
- A. Lying prone with arms above head
- B. Side lying on the unaffected side
- C. Side lying on the affected side
- D. Upright position, leaning forward over an over-bed tray table
Correct Answer: D
Rationale: The upright position leaning forward (D) maximizes lung expansion and access to pleural fluid during thoracentesis.
The nurse is admitting a client directly from a health provider's office. The client has a rash and has been diagnosed with measles. Which room assignment by the nurse indicates an understanding of the disease process of measles?
- A. a private negative-pressure room
- B. a semiprivate room with a client who has a broken femur
- C. a semiprivate room with a client diagnosed with type 1 diabetes
- D. a private room at the end of the hall away from the nurses' station
Correct Answer: A
Rationale: Measles requires airborne precautions, necessitating a private negative-pressure room to prevent transmission.
The nurse observes a 2 1/2-year-old toddler in the waiting room. Based on expected child development, the nurse expects to see the child engaged in which type of play?
- A. playing alone, with no interaction with other children
- B. playing cooperatively in a single-sex group
- C. playing parallel to other children, but not playing together
- D. playing and interacting cooperatively in a mixed-sex group
Correct Answer: C
Rationale: Toddlers (2-3 years) engage in parallel play, playing alongside but not cooperatively with others, due to developing social skills.
The nurse is teaching a client with a new diagnosis of heart failure about sodium restriction. Which of the following foods should the client avoid?
- A. Fresh apples.
- B. Canned soups.
- C. Baked chicken.
- D. Brown rice.
Correct Answer: B
Rationale: canned soups are high in sodium, which should be limited in heart failure to prevent fluid retention