Nokea
What is the correct documentation of the patient's peripheral pulse when the finding is that the posterior tibial pulse is weak and thready?
- A. Grade C posterior tibial pulse
- B. Posterior tibial pulse is Grade B
- C. The client's posterior tibial is 2
- D. Posterior tibial pulse is 1
Correct Answer: D
Rationale: A weak and thready pulse is documented as a 1+ on a 0-4 scale, where 1 indicates a barely palpable pulse.
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The nurse assists the code team with an unresponsive and pulseless client. Which intervention does the nurse prepare for based on the electrocardiogram (ECG) tracing? See the image below.
- A. Prepare an infusion of sodium bicarbonate
- B. Administer epinephrine
- C. Defibrillation
- D. Cardioversion
Correct Answer: C
Rationale: Defibrillation is the treatment for pulseless ventricular fibrillation or ventricular tachycardia, per ACLS guidelines.
The nurse has instructed a client with hyperlipidemia about self-management. Which statement by the client would require follow-up by the nurse?
- A. I should replace hydrogenated vegetable oils with canola oil when cooking.
- B. I should increase my intake of fish like tuna and salmon more often.
- C. Increasing my fiber intake will help lower my cholesterol.
- D. I am glad that I won't need to reduce red meat from my diet.
Correct Answer: D
Rationale: Red meat is high in saturated fat, which worsens hyperlipidemia. The client needs dietary education.
The nurse in the emergency department (ED) is triaging a client with acute chest pain. The nurse should initially
- A. insert a peripheral venous access device (VAD).
- B. obtain a 12-lead electrocardiogram (ECG).
- C. obtain a point-of-care troponin level.
- D. auscultate lung sounds.
Correct Answer: B
Rationale: A 12-lead ECG is the initial step in evaluating acute chest pain to identify myocardial ischemia or infarction.
History of Present Illness (HPI)
The client was found disoriented upon arrival and in acute respiratory distress.
The client's caregiver noted that the prescribed medications had not been
taken for several days. Medical history includes hypertension, diabetes mellitus,
congestive heart failure, and arthritis. Client Assessment Bounding peripheral pulses,
normotensive, crackles in the lung fields, tachypnea, jugular venous distention, and
abdominal distention.
Diagnosis
1. Pulmonary edema
2. Acute decompensated heart failure
Based on the clinical data, which prescription would the nurse request from the primary healthcare provider for a client with pulmonary edema and acute decompensated heart failure? Select all that apply.
- A. Albuterol
- B. Hydrocortisone
- C. Diltiazem
- D. Nitroglycerin
- E. Furosemide
Correct Answer: D,E
Rationale: Albuterol is for bronchospasm, not pulmonary edema. B: Incorrect - Hydrocortisone is not indicated for heart failure. C: Incorrect - Diltiazem is for rate control, not fluid overload. D: Correct - Nitroglycerin reduces preload, alleviating pulmonary edema. E: Correct - Furosemide is a diuretic to reduce fluid overload.
The nurse is providing discharge teaching to a client following coronary artery bypass graft (CABG) surgery. The nurse should advise the client that they may resume sexual activity
- A. after exercise tolerance is assessed.
- B. one week after surgery.
- C. when the client can comfortably jog two miles.
- D. three months after surgery.
Correct Answer: A
Rationale: Sexual activity can resume after CABG once exercise tolerance is confirmed, typically when the client can climb two flights of stairs without symptoms.