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Ventricular tachycardia is displayed on the cardiac monitor of a client admitted to the telemetry unit. Which should the nurse do first?
- A. Prepare for immediate cardioversion.
- B. Begin cardiopulmonary resuscitation (CPR).
- C. Check for a pulse.
- D. Prepare for immediate defibrillation.
Correct Answer: C
Rationale: Checking for a pulse determines if ventricular tachycardia is pulseless (requiring defibrillation) or stable (possibly requiring cardioversion or medication).
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A nurse assesses a 40-year-old female client with vasospastic disorder (Raynaud’s phenomenon) involving her right hand. The nurse notes the information in the progress notes, as shown below. From these fi ndings, the nurse should formulate which priority nursing diagnosis?
- A. Acute pain related to hyperemic stage
- B. Disturbed sensory perception (tactile) related to vasospastic process.
- C. Ineffective tissue perfusion (peripheral) related to vasospastic process.
- D. Risk for impaired skin integrity related to vasospastic process.
Correct Answer: B
Rationale: The client complains of numbness in her fingertips, thus Disturbed sensory perception (tactile) is the priority nursing diagnosis. The client does not complain of acute pain. The other data suggest that the circulation is adequate at this time, so neither Ineffective tissue perfusion nor Risk for impaired skin integrity is the priority nursing diagnosis.
A client who had a splenectomy is being discharged. Of the following discharge instructions, which is most specific to the client's surgical procedure?
- A. Do not drive.
- B. Alternate rest and activity.
- C. Make an appointment for the staples to be removed.
- D. Report early signs of infection.
Correct Answer: D
Rationale: Splenectomy increases the lifelong risk of infection due to the spleen's role in immunity. Reporting early signs of infection is the most specific instruction, as it addresses this unique risk. The other instructions are general postoperative advice.
When developing a discharge plan to manage the care of a client with chronic obstructive pulmonary disease (COPD), the nurse should advise the client to expect to:
- A. Develop respiratory infections easily.
- B. Maintain current status.
- C. Require less supplemental oxygen.
- D. Show permanent improvement.
Correct Answer: A
Rationale: COPD clients are prone to respiratory infections due to impaired lung defenses. Maintaining status is possible but not an expectation. Oxygen needs may increase, and COPD is progressive, not permanently improved.
A client with renal calculi is prescribed tamsulosin. The nurse explains it:
- A. Dissolves stones.
- B. Relaxes ureter muscles.
- C. Reduces urine output.
- D. Prevents infection.
Correct Answer: B
Rationale: Tamsulosin relaxes ureter muscles, aiding stone passage.
A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which of the following indicates this client is ready to be discharged?
- A. The client voids 500 mL of urine.
- B. The client tolerates eating a hamburger.
- C. The client is pain-free.
- D. The client walks in the hallway unassisted.
Correct Answer: A
Rationale: Voiding 500 mL indicates normal bladder function, a key discharge criterion after hernia repair, ensuring no urinary retention from anesthesia or surgery.