Nokea
Upon assessment of third degree heart block on the monitor, the nurse should first:
- A. Call a code.
- B. Begin cardiopulmonary resuscitation.
- C. Have transcutaneous pacing ready at the bedside.
- D. Prepare for defibrillation.
Correct Answer: C
Rationale: Third-degree heart block may require pacing. Having transcutaneous pacing ready is the first step to manage symptomatic bradycardia.
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A client with diabetes mellitus comes to the clinic for a regular 3-month follow-up appointment. The nurse notes several small bandages covering cuts on the client's hands. The client says, 'I'm so clumsy. I'm always cutting my finger cooking or burning myself on the iron.' Which of the following responses by the nurse would be most appropriate?
- A. Soak small wounds in isopropyl alcohol.'
- B. Keep all cuts clean and covered.'
- C. Why don't you have your children do the cooking and ironing?'
- D. You really should be fine as long as you take your daily medication.'
Correct Answer: B
Rationale: Keeping cuts clean and covered prevents infection, a significant risk in diabetes due to poor wound healing.
A client post-cystoscopy is discharged. The nurse should instruct to:
- A. Resume normal activity.
- B. Avoid fluids for 24 hours.
- C. Expect blue urine.
- D. Take antibiotics for a week.
Correct Answer: A
Rationale: Normal activity can resume post-cystoscopy unless complications arise.
Which of the following interventions is most appropriate for a client who has stomatitis?
- A. Drinking hot tea at frequent intervals.
- B. Gargling with antiseptic mouthwash.
- C. Using an electric toothbrush.
- D. Eating a soft, bland diet.
Correct Answer: D
Rationale: Stomatitis involves inflammation of the oral mucosa, often causing pain and sensitivity. A soft, bland diet is most appropriate as it minimizes irritation and discomfort during eating. Hot tea, antiseptic mouthwash, and electric toothbrushes can exacerbate irritation or pain in the inflamed oral tissues.
What is the purpose of straining urine in a client with renal calculi?
- A. Detect blood.
- B. Identify stone composition.
- C. Measure urine volume.
- D. Prevent infection.
Correct Answer: B
Rationale: Straining urine captures stones for analysis to determine composition.
The nurse is caring for a client in the emergency department (ED) who sustained a high-voltage (major) electrical burn. Which laboratory data should the nurse monitor to determine if the client is experiencing a complication from this injury?
- A. Creatine phosphokinase (CK)
- B. White blood cells
- C. Serum lipase
- D. Serum glucose
Correct Answer: A
Rationale: High-voltage electrical burns can cause muscle damage, releasing creatine phosphokinase (CK) into the blood, indicating rhabdomyolysis. Monitoring CK levels helps detect complications like renal failure. White blood cells (B), lipase (C), and glucose (D) are less specific for electrical burn complications.