Nokea
The telemetry monitor technician notifies the nurse of the morning telemetry readings. Which client should the nurse assess first?
- A. The client in normal sinus rhythm with a peaked T wave.
- B. The client diagnosed with atrial fibrillation with a rate of 100.
- C. The client diagnosed with a myocardial infarction who has occasional PVCs.
- D. The client with a first-degree atrioventricular block and a rate of 92.
Correct Answer: A
Rationale: Peaked T waves indicate hyperkalemia, which can lead to life-threatening arrhythmias, requiring immediate assessment. Atrial fibrillation, PVCs, and first-degree AV block are less urgent unless unstable.
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On the basis of the nurse's knowledge of patient rights, which Federal law has the PCT violated?
- A. Good samarian Act
- B. Uncontractic Oath
- C. Health Insurance Portability and Accountability Act (HIPAA)
- D. Emergency Medical Treatment and Liability Act (EMTALA)
Correct Answer: C
Rationale: The PCT violated HIPAA by discussing the client's condition loudly in a public area, compromising patient confidentiality.
When the client with an ileal conduit asks about resuming physical activity, which response by the nurse is most appropriate?
- A. Avoid all strenuous activity permanently.
- B. Resume activities gradually as tolerated.
- C. Wait at least 6 months before exercising.
- D. Limit activity to walking only.
Correct Answer: B
Rationale: Resuming activities gradually as tolerated allows the client to regain strength while protecting the stoma.
Which nursing intervention is most helpful in assisting the client undergoing hemodialysis to cope with the client and the patient to the patient?
- A. Giving the client literature to read about renal failure
- B. Advising the client's spouse to cook the client's favorite dishes
- C. Keeping the client informed of the latest research findings
- D. Exploring with the client how this disorder has affected life
Correct Answer: D
Rationale: Exploring the impact of the disorder on the client's life fosters emotional coping and supports psychosocial adjustment.
The nurse and a licensed practical nurse (LPN) are caring for a group of clients. Which intervention should be assigned to the LPN?
- A. Assessment of the client who has had a Kock pouch procedure.
- B. Monitoring of the postop client with a WBC of 22,000/mm3.
- C. Administration of the prescribed antineoplastic medications.
- D. Care for the client going for an MRI of the kidneys.
Correct Answer: D
Rationale: Caring for a client going for an MRI involves routine tasks (e.g., transport, preparation) within an LPN’s scope. Assessment, monitoring high WBC, and administering chemotherapy require RN judgment.
The client asks, 'What does an elevated PSA test mean?' On which scientific rationale should the nurse base the response?
- A. An elevated PSA can result from several different causes.
- B. An elevated PSA can be only from prostate cancer.
- C. An elevated PSA can be diagnostic for testicular cancer.
- D. An elevated PSA is the only test used to diagnose BPH.
Correct Answer: A
Rationale: Elevated PSA can result from prostate cancer, BPH, prostatitis, or other factors, requiring further evaluation. It is not specific to prostate cancer, testicular cancer, or BPH diagnosis alone.