Nokea
What is an important nursing responsibility when a dysrhythmia is suspected?
- A. Order an immediate electrocardiogram
- B. Count the radial pulse every minute for five times
- C. Count the apical pulse for 1 full minute and compare the rate with the radial pulse rate
- D. Have someone else take the radial pulse simultaneously with the apical pulse
Correct Answer: C
Rationale: When a dysrhythmia is suspected, it is important for nurses to count the apical pulse for a full minute and compare it with the radial pulse rate. This method helps in identifying dysrhythmias because discrepancies between the apical and radial pulse rates can indicate irregular heart rhythms. Option A is incorrect because ordering an immediate electrocardiogram may not always be feasible or necessary as a first step. Option B, counting the radial pulse multiple times, is less accurate than comparing the apical and radial pulse rates. Option D involves an unnecessary step of having another person take simultaneous pulses when the nurse can do it effectively alone.
You may also like to solve these questions
A nurse is caring for an infant with intractable vomiting. For what complication is it most important for the nurse to assess?
- A. Acidosis
- B. Alkalosis
- C. Hyperkalemia
- D. Hypernatremia
Correct Answer: B
Rationale: When an infant experiences intractable vomiting, it can lead to the loss of stomach acids, resulting in metabolic alkalosis. Alkalosis is characterized by elevated blood pH and can lead to serious complications. Assessing for alkalosis is essential in this scenario to monitor and manage the infant's condition. Choices A, C, and D are incorrect because in this context, the primary concern is the metabolic imbalance caused by excessive vomiting, leading to alkalosis rather than acidosis, hyperkalemia, or hypernatremia.
What is an important nursing responsibility when a dysrhythmia is suspected?
- A. order an immediate electrocardiogram
- B. count the radial pulse every 1 minute for five times
- C. count the apical pulse for 1 full minute, and compare the rate with the radial pulse rate
- D. have someone else take the radial pulse simultaneously with the apical pulse
Correct Answer: C
Rationale: When a dysrhythmia is suspected, an important nursing responsibility is to count the apical pulse for 1 full minute and then compare this rate with the radial pulse rate. This method helps in identifying dysrhythmias as it allows for a direct comparison of the heart's rhythm at two different pulse points. Ordering an immediate electrocardiogram (Choice A) may be necessary but should not be the first step. Counting the radial pulse multiple times (Choice B) is not as accurate as comparing rates directly. Having someone else take the radial pulse simultaneously (Choice D) may introduce errors and inconsistencies in the measurement.
What finding would the nurse expect to assess in a child with hypothyroidism?
- A. Nervousness
- B. Heat intolerance
- C. Smooth velvety skin
- D. Weight gain
Correct Answer: D
Rationale: In a child with hypothyroidism, weight gain is a typical finding due to the slowed metabolism associated with the condition. This occurs because thyroid hormone levels are insufficient to regulate metabolism effectively. Choices A, B, and C are not typically associated with hypothyroidism. Nervousness is more commonly seen in conditions like hyperthyroidism, where there is an excess of thyroid hormones. Heat intolerance may be seen in hyperthyroidism as well, where the body's metabolism is increased. Smooth velvety skin is a characteristic finding in conditions like Cushing's syndrome, where there is excess cortisol production.
The nurse is assessing a 4-year-old client. Which finding suggests to the nurse this child may have a genetic disorder?
- A. The inquiry determines the child had feeding problems.
- B. The child weighs 40 lb (18.2 kg) and is 40 in (101.6 cm) in height.
- C. The child has low-set ears with lobe creases.
- D. The child can hop on one foot but cannot skip.
Correct Answer: C
Rationale: Low-set ears with lobe creases are often associated with genetic disorders, such as Down syndrome, and can indicate underlying chromosomal abnormalities. This physical characteristic is a common feature seen in various genetic syndromes. The other choices, including feeding problems, weight and height measurements, and motor skills, are not typically specific indicators of genetic disorders in the absence of other associated features.
A 3-year-old child is being discharged after being treated for dehydration. What should be included in the discharge teaching?
- A. Monitor for signs of infection
- B. Monitor for signs of dehydration
- C. Monitor for signs of hypovolemia
- D. Monitor for signs of malnutrition
Correct Answer: B
Rationale: The correct answer is to monitor for signs of dehydration. After treatment for dehydration, it is crucial to educate caregivers about recognizing early signs of dehydration to prevent its recurrence. Monitoring for dehydration ensures that appropriate measures can be taken promptly if signs reappear. Choices A, C, and D are incorrect because infection, hypovolemia, and malnutrition, while important considerations in healthcare, are not the primary focus after treating dehydration in a 3-year-old child.