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The nurse notices that a client's heart rate decreases from 63 to 50 beats per minute on the monitor. The nurse should first:
- A. Administer Atropine 0.5 mg I.V. push.
- B. Auscultate for abnormal heart sounds.
- C. Prepare for transcutaneous pacing.
- D. Take the client's blood pressure.
Correct Answer: D
Rationale: A heart rate of 50 bpm may indicate bradycardia. Taking the blood pressure first assesses hemodynamic stability, guiding whether immediate intervention (e.g., atropine or pacing) is needed.
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The nurse is preparing to transfuse platelets to a client. Which of the following actions would be appropriate for the nurse to take? Select all that apply.
- A. Obtain the client's weight
- B. Ensure ABO type compatibility
- C. Infuse the platelets over 2 to 4 hours
- D. Verify completed consent for platelet transfusion
- E. Obtain pre-transfusion vital signs
Correct Answer: B,D,E
Rationale: Ensuring ABO compatibility prevents transfusion reactions, verifying consent ensures legal and ethical standards, and obtaining pre-transfusion vital signs establishes a baseline for monitoring. Platelet infusions are typically rapid (15–30 minutes), not 2–4 hours, and weight is not routinely required unless dosing is weight-based.
The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which of the following positions are appropriate?
- A. Placing a pillow in the axilla so the arm is away from the body.
- B. Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow.
- C. Immobilizing the extremity in a sling.
- D. Positioning a hand cone in the hand so the fingers are barely flexed.
- E. Keeping the arm at the side using a pillow.
Correct Answer: A,D
Rationale: Placing a pillow in the axilla (A) prevents adduction contractures, and a hand cone (D) maintains slight finger flexion to avoid claw-hand deformity. A sling or keeping the arm at the side may promote contractures, and elevating the hand above the elbow is less critical.
When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to:
- A. Decreased blood volume
- B. Increase in muscular activity
- C. Increased venous pressure
- D. Increased arterial pressure
Correct Answer: C
Rationale: Bilateral ankle edema in PVD is often due to increased venous pressure from venous insufficiency or right-sided heart failure, which impairs venous return and causes fluid to pool in the lower extremities. Decreased blood volume or increased muscular activity does not cause edema, and arterial pressure is not directly related.
A client with advanced Hodgkin's disease is admitted to hospice because death is imminent. The goal to address for the client is:
- A. Fear of pain.
- B. Fear of further therapy.
- C. Feelings of isolation.
- D. Feelings of social inadequacy.
Correct Answer: A
Rationale: In hospice care for advanced Hodgkin's disease, the primary goal is to address fear of pain, ensuring comfort as death approaches. Fear of therapy, isolation, and social inadequacy are less relevant at this stage.
The client with peripheral vascular disease has been prescribed diltiazem (Cardizem). The nurse should determine the effectiveness of this medication by assessing the client for:
- A. Relief of anxiety
- B. Sedation
- C. Vasoconstriction
- D. Vasodilation
Correct Answer: D
Rationale: Diltiazem, a calcium channel blocker, promotes vasodilation in PVD, improving blood flow and reducing claudication symptoms. The nurse assesses for vasodilation (e.g., reduced pain, warmer extremities). It does not primarily relieve anxiety, cause sedation, or promote vasoconstriction.