Nokea
To assess the area where the permanent pacemaker battery, the nurse knows to examine which area of the skin?
- A. Beneath the left nipple
- B. Near the brachial artery
- C. In the midsternal area
- D. Below the right clavicle
Correct Answer: D
Rationale: Pacemaker generators are typically implanted below the right clavicle.
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The best evidence that the client understands the nurse's instructions regarding dietary restrictions is if the client states to avoid which food?
- A. Canned soup
- B. Fresh fruit
- C. Baked chicken
- D. Whole grain bread
Correct Answer: A
Rationale: Canned soup is high in sodium, which should be avoided in a low-sodium diet for hypertension management. The other options are generally low-sodium and suitable.
When the nurse is about to administer digoxin to a client, the client says, 'I think I need to see the eye doctor. Things seem to look kind of green today.' The nurse takes his vital signs, which are blood pressure = 150/94, pulse = 60 bpm, and respirations = 28. What is the most appropriate initial action for the nurse to take?
- A. Administer the medication and record the findings on his chart
- B. Withhold the digoxin and report to the charge nurse
- C. Request an appointment with the ophthalmologist
- D. Reassure the client that he is having a normal reaction to his medication
Correct Answer: B
Rationale: Visual disturbances, such as seeing a green or yellow halo, are signs of digoxin toxicity. The nurse should withhold the medication and report to the charge nurse for further evaluation.
The nurse enters the client's room and notes an unconscious client with an absence of respirations and no pulse or blood pressure. The concept of perfusion is identified by the nurse. Which should the nurse implement first?
- A. Notify the health care provider.
- B. Call a rapid response team (RRT).
- C. Determine the telemetry monitor reading.
- D. Push the Code Blue button.
Correct Answer: D
Rationale: No pulse/respirations indicate cardiac arrest; pushing the Code Blue button (D) initiates the code team. Notifying HCP (A), RRT (B), or checking telemetry (C) delay resuscitation.
What should be included in foot care for the client who has a peripheral vascular disorder?
- A. Soaking the feet for 20 minutes before washing them
- B. Walking barefoot only on carpeted floors
- C. Applying lotion between the toes to avoid cracking of the skin
- D. Avoiding exposure of the legs and feet to the sun
Correct Answer: D
Rationale: Avoiding sun exposure prevents skin damage in clients with compromised circulation due to peripheral vascular disease. Soaking, walking barefoot, or applying lotion between toes increase infection or injury risk.
During the admission interview, a client who is admitted for a cardiac catheterization says, 'Every time I eat shrimp I get a rash.' What action is essential for the nurse to take at this time?
- A. Notify the physician.
- B. Ask the client if she gets a rash from any other foods.
- C. Instruct the dietary department not to give the client shrimp.
- D. Teach the client the dangers of eating shrimp and other shellfish.
Correct Answer: A
Rationale: A shrimp allergy may indicate an iodine allergy, as shellfish contain iodine, which is also present in the dye used for cardiac catheterization. Notifying the physician is essential to assess the risk and consider alternative dyes or premedication. Asking about other foods, instructing the dietary department, or teaching about shellfish dangers are secondary actions.