Nokea
The rapid response team has been called to manage an unwitnessed cardiac arrest. The estimated maximum time a person can be without cardiopulmonary function and still not experience permanent brain damage is:
- A. 1 to 2 minutes.
- B. 4 to 6 minutes.
- C. 8 to 10 minutes.
- D. 12 to 15 minutes.
Correct Answer: B
Rationale: Brain damage begins after 4 to 6 minutes without oxygenation, making this the critical window for initiating CPR to prevent permanent damage.
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When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply.
- A. Verify patency of the line by the presence of a blood return at regular intervals.
- B. Inspect the insertion site for swelling, erythema, or drainage.
- C. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.
- D. If unable to aspirate blood, reposition the client and encourage the client to cough.
- E. Contact the health care provider about verifying placement if the status is questionable.
Correct Answer: A,B,D,E
Rationale: Verifying patency (A), inspecting the site (B), repositioning for no blood return (D), and contacting the provider if placement is questionable (E) are critical to ensure safe chemotherapy administration. Administering without blood return (C) risks extravasation and tissue damage.
The family members caring for a 72-year-old client who is near death from colon cancer are concerned about dehydration. What should the nurse tell them about dehydration at end of life?
- A. The physician will make the decision regarding hydration therapy.
- B. Dehydration may prolong the dying process.
- C. Hydration is used only in extreme situations of dehydration.
- D. Dehydration is expected during the dying process.
Correct Answer: D
Rationale: Dehydration is a natural part of the dying process and is often not treated aggressively in hospice care, as it may not cause discomfort and can reduce symptoms like edema.
A client with a large goiter is scheduled for a subtotal thyroidectomy to treat thyrotoxicosis. Saturated solution of potassium iodide (SSKI) is prescribed preoperatively for the client. The primary reason for using this drug is that it helps:
- A. Slow progression of exophthalmos.
- B. Reduce the vascularity of the thyroid gland.
- C. Decrease the body's ability to store thyroxine.
- D. Increase the body's ability to excrete thyroxine.
Correct Answer: B
Rationale: SSKI reduces the vascularity of the thyroid gland, making surgery safer by decreasing the risk of bleeding. It does not primarily affect exophthalmos, thyroxine storage, or excretion.
Pseudoephedrine (Sudafed) has been ordered as a nasal decongestant. Which of the following is a possible adverse effect of this drug?
- A. Constipation.
- B. Bradycardia.
- C. Diplopia.
- D. Restlessness.
Correct Answer: D
Rationale: Pseudoephedrine is a sympathomimetic that can cause central nervous system stimulation, leading to restlessness. Constipation, bradycardia, and diplopia are not common adverse effects of this medication.
A client is to receive epoetin (Epogen) injections. What laboratory value should the nurse assess before giving the injection?
- A. Hematocrit.
- B. Partial thromboplastin time.
- C. Hemoglobin concentration.
- D. Prothrombin time.
Correct Answer: A
Rationale: Epoetin (Epogen) stimulates red blood cell production and is used to treat anemia. The nurse should assess hematocrit before administration to evaluate the client's response to therapy and ensure levels do not rise excessively, which can increase the risk of hypertension or thrombosis. Hemoglobin is also relevant but hematocrit is more commonly monitored. Coagulation times are not directly affected by epoetin.