Nokea
When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12. Which action should the nurse take first?
- A. Try to vigorously stimulate normal breathing.
- B. Ask the RN to assess the vital signs.
- C. Measure the pulse oximetry.
- D. Continue to monitor respirations.
Correct Answer: C
Rationale: Pulse oximetry provides critical data on oxygenation.
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What is an example of a pertinent negative finding during a physical examination?
- A. Chest pain that does not radiate to the arm
- B. Elevated blood pressure in a patient with hypertension
- C. Pupils that are equal and react to light and accommodation
- D. Clear and full lung sounds in a patient with chronic bronchitis
Correct Answer: A
Rationale: The correct answer is 'Chest pain that does not radiate to the arm.' Pertinent negatives highlight clinically significant absences of expected findings, helping rule out certain conditions like cardiac ischemia.
When teaching a group of clients about emergency care for a snake bite, which of the following information should the nurse include?
- A. Raise the affected extremity above the level of the heart.
- B. Immobilize the affected extremity with a splint
- C. Apply ice to the bite area
- D. Apply a tourniquet to the affected extremity.
Correct Answer: B
Rationale: The correct answer is B: Immobilize the affected extremity with a splint. This is important to prevent the spread of venom through the lymphatic system. Elevating the extremity (A) can increase the spread of venom. Applying ice (C) can constrict blood vessels, trapping venom in the area. Applying a tourniquet (D) can lead to tissue damage and worsen the condition. Immobilizing with a splint is the most effective way to limit movement and venom spread.
You are admitting an elderly client to the medical unit. Which factor indicates that this client has a risk for acid-base imbalances?
- A. Myocardial infarction 1 year ago
- B. Occasional use of antacids
- C. Shortness of breath with extreme exertion
- D. Chronic renal insufficiency
Correct Answer: D
Rationale: The correct answer is D: Chronic renal insufficiency. Chronic renal insufficiency can lead to metabolic acidosis or alkalosis due to impaired kidney function in regulating acid-base balance. Renal insufficiency can cause retention or loss of bicarbonate ions, leading to imbalances. Myocardial infarction, occasional use of antacids, and shortness of breath with extreme exertion are not direct risk factors for acid-base imbalances.
What statement indicates Mr. Singer understands his condition after viewing a filmstrip on rehabilitation?
- A. ‘I will be able to continue my swimming as usual.’
- B. ‘I will regain some degree of my sense of smell and taste.’
- C. ‘I will not be able to bowl any more.’
- D. ‘I will have to give up my tub bath.’
Correct Answer: B
Rationale: Partial recovery of senses is possible after laryngectomy.
What should the nurse do if Wendy develops moderate hypotension and irregular pulse while receiving aminophylline?
- A. Check apical pulse and blood pressure every 10 minutes and continue present aminophylline administration
- B. Discontinue the aminophylline drip and call the physician
- C. Rapidly administer epinephrine 1:1000 intravenously
- D. Slow the rate of aminophylline administration, monitor vital signs, and notify physician
Correct Answer: D
Rationale: Adjusting the infusion rate prevents further adverse effects.