Nokea
The nurse on a medical surgical unit enters a room, finds a client unresponsive with no pulse, and starts 2 minutes of CPR. The nurse receives and attaches an automated external defibrillator, but no shock is advised. Which action should the nurse perform next?
- A. Check for a carotid pulse for at least 10 seconds
- B. Provide rescue breaths at a rate of 10-12/min
- C. Resume chest compressions at a rate of 100/min
- D. Use the jaw-thrust maneuver to assess the airway
Correct Answer: C
Rationale: If no shock is advised, CPR should resume immediately with chest compressions to restore circulation.
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An adult who recently had an amputation has an above-the-knee prosthesis. Which nursing action will do the most to help the client adjust to the prosthesis?
- A. Adjust the prosthesis for the client.
- B. Offer the client a cane or a walker for ease of movement.
- C. Place an 'at risk for fall' sign on the client's door.
- D. Allow the client to manage his own care.
Correct Answer: D
Rationale: Allowing self-management fosters independence and confidence with the prosthesis, promoting adjustment.
Which of the following medications is not considered a neuromuscular blocker?
- A. Anectine
- B. Pavulon
- C. Pitressin
- D. Mivacron
Correct Answer: C
Rationale: Pitressin is a hormone replacement medication.
The nurse is caring for a client with chronic venous insufficiency. Which of the following findings would be consistent with the condition?
- A. absent pedal pulses bilaterally
- B. toes cold to palpation bilaterally
- C. absence of hair on the lower extremities
- D. brown, hardened skin on the lower extremities
Correct Answer: D
Rationale: Brown, hardened skin (lipodermatosclerosis) is characteristic of chronic venous insufficiency due to hemosiderin deposition and fibrosis.
An adult is hospitalized following a myocardial infarction. While the client is receiving heparin, the nurse should have which of the following medications available?
- A. Aspirin
- B. Calcium gluconate
- C. Vitamin K
- D. Protamine sulfate
Correct Answer: D
Rationale: Protamine sulfate is the antidote for heparin overdose, reversing its anticoagulant effects in case of bleeding.
The nurse is observing a client who had a left total knee replacement using a cane to descend stairs. It would demonstrate correct technique if the client descends the stairs by placing the
- A. cane on the step first, followed by the affected leg, and then the unaffected leg
- B. cane on the step first, followed by the unaffected leg, and then the affected leg
- C. affected leg on the step first, followed by the cane, and then the unaffected leg
- D. unaffected leg on the step first, followed by the affected leg, and then the cane
Correct Answer: A
Rationale: For descending stairs, the cane and affected leg move together after the unaffected leg, providing stability.