Nokea
The nurse reviewing the electrocardiogram (ECG) rhythm strip of a client with a history of a myocardial infarction (MI) notes that the PR intervals are 0.16 seconds. The nurse should arrive at which interpretation of this assessment data?
- A. A normal finding
- B. An abnormal finding
- C. An impending reinfarction
- D. First-degree atrioventricular (AV) block
Correct Answer: A
Rationale: The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The PR interval range is 0.12 to 0.2 seconds. Therefore, the finding is normal. The remaining options all indicate an abnormal finding, so they are not appropriate responses.
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The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse determines that the UAP understands the type of information to report to the nurse when the UAP reports which of the following about one of the clients?
- A. An episode of nausea after administration of an epidural anesthetic.
- B. Contractions 3 minutes apart and lasting 40 seconds.
- C. Scream of spontaneous rupture of the membranes.
- D. Sleeping after administration of I.V. nalbuphine (Nubain).
Correct Answer: A,C
Rationale: Nausea after an epidural and spontaneous rupture of membranes are significant events requiring nurse assessment due to potential complications. Contractions and sleeping are expected findings.
The nurse is teaching a client with a new diagnosis of atrial fibrillation about dabigatran (Pradaxa). Which of the following instructions is most important?
- A. Take the medication with food to reduce stomach upset.
- B. Report any signs of bleeding immediately.
- C. Avoid taking the medication with aspirin.
- D. Store the medication in the refrigerator.
Correct Answer: B
Rationale: Dabigatran, an anticoagulant, increases bleeding risk, so reporting signs of bleeding is critical for safety.
A client with a history of schizophrenia is prescribed olanzapine (Zyprexa). The nurse should monitor the client for which of the following adverse effects?
- A. Weight gain.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: A
Rationale: Olanzapine commonly causes weight gain, requiring monitoring.
You are caring for a client whose pressure ulcer is yellow. Which treatment will you most likely employ for this wound?
- A. A barrier film
- B. An alginate dressing
- C. Surgical laser debridement
- D. Autolytic debridement
Correct Answer: D
Rationale: A yellow pressure ulcer indicates slough, best treated with autolytic debridement to promote natural tissue breakdown and healing.
Your 87 year old client has a history of heart disease and fibromyalgia. This client has an internal pacemaker and is also a diabetic client. During your annual visit with this client, the client tells you that they would like to begin some alternative and homeopathic health care practices. What should you include in your teaching plan for this client?
- A. Information about the lack of scientific evidence regarding the effectiveness of all herbs.
- B. Data to support the fact that magnets can be effective in terms of fibromyalgia pain, and as such, may be a good choice for this client.
- C. Research that suggests that prayer is an effective alternative method to relieve pain and stress that can be helpful to this client.
- D. Information that contraindicates the use of biofeedback because this alternative, complementary health practice can interfere with the client's pacemaker functioning.
Correct Answer: C
Rationale: Prayer is a safe and evidence-supported complementary practice that can help reduce stress and pain, suitable for this client. There is insufficient evidence for magnets in fibromyalgia treatment, and biofeedback is not contraindicated for pacemakers. Not all herbs lack scientific evidence, so option A is overly broad.