Nokea
The nurse providing emergency treatment for a client in ventricular tachycardia is preparing to defibrillate the client. Which nursing action provides for the safest environment during a defibrillation attempt?
- A. Ensuring that no lubricant is on the paddles
- B. Placing the charged paddles one at a time on the client's chest
- C. Holding the client's upper torso stable while the defibrillation is performed
- D. Assuring that all assisting personnel are clear of the client and the client's bed
Correct Answer: D
Rationale: Safety during defibrillation is essential for preventing injury to the client and the personnel assisting with the procedure. The person performing the defibrillation ensures that all personnel are standing clear of the bed by a verbal and visual check of 'all clear.' For the shock to be effective, some type of conductive medium (e.g., lubricant, gel) must be placed between the paddles and the skin. Both paddles are placed on the client's chest.
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The charge nurse on the postpartum unit has received report about a client with a fetal demise who has just delivered and will be ready for transfer out of Labor and Delivery in about 2 hours. The client has asked her primary nurse if she can stay on the unit since she found support from the nursing staff there. What action should the charge nurse on the postpartum unit take?
- A. Request a room for this client on a unit without newborns.
- B. Ask the nurse in labor and delivery to discharge the mother as soon as she is physically able to leave.
- C. Talk to the mother first and decide on a location that is mutually agreeable.
- D. Admit the mother to a private room on the postpartum unit.
Correct Answer: A
Rationale: Placing the client on a unit without newborns minimizes emotional distress from being near other newborns after a fetal demise.
When teaching a group of parents about the potential for febrile seizures in children, which of the following facts should the nurse include?
- A. The exact cause is known.
- B. The seizures occur as the fever rises.
- C. Children older than age 3 are most at risk.
- D. These seizures commonly occur after immunization administration.
Correct Answer: B
Rationale: Febrile seizures typically occur as the fever rises rapidly in young children (usually under age 5), not specifically after immunizations or in older children.
The nurse is teaching a client with a new colostomy about dietary choices. Which of the following foods should the nurse recommend to prevent odor and gas?
- A. Yogurt.
- B. Broccoli.
- C. Cabbage.
- D. Beans.
Correct Answer: A
Rationale: Yogurt contains probiotics that can reduce gas and odor in colostomy output, unlike broccoli, cabbage, or beans.
The nurse is caring for a client with a history of atrial fibrillation who is prescribed sotalol (Betapace). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Bradycardia.
- C. Hyperglycemia.
- D. Weight gain.
Correct Answer: B
Rationale: Sotalol, a beta-blocker, can cause bradycardia, requiring close monitoring of heart rate.
Which statement about referrals is accurate?
- A. Referrals complement the healthcare teams' abilities to provide optimal care to the client.
- B. Referrals simply allow the client to be discharged into the community with the additional care they need.
- C. Nurses facilitate referrals to only the resources within the facility.
Correct Answer: A
Rationale: Referrals enhance the healthcare team's ability to provide comprehensive care by connecting clients to specialized services, not limited to discharge or internal resources .