Nokea
When evaluating a client's understanding of wearing a Holter monitor, which statement made by the client would indicate to the nurse that the client understands the procedure?
- A. I must record any symptoms occurring with my activity.
- B. I am not looking forward to staying in bed for 24 hours.
- C. I really am dreading the frequent blood drawing.
- D. I know that I shouldn't get close to my microwave oven.
Correct Answer: A
Rationale: The correct answer is A because it demonstrates the client understands the purpose of wearing a Holter monitor—to record symptoms related to activity. This shows the client comprehends the importance of monitoring symptoms accurately. Choices B, C, and D are incorrect because they do not relate to the purpose of wearing a Holter monitor or indicate an understanding of the procedure. B focuses on personal preference, C on unrelated procedures, and D on irrelevant safety precautions.
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A client with cirrhosis of the liver is being cared for by the healthcare team. Which clinical manifestation indicates that the client has developed hepatic encephalopathy?
- A. Asterixis.
- B. Jaundice.
- C. Ascites.
- D. Splenomegaly.
Correct Answer: A
Rationale: The correct answer is A: Asterixis. Hepatic encephalopathy is a neuropsychiatric syndrome associated with liver dysfunction. Asterixis, also known as liver flap, is a key clinical manifestation characterized by a flapping tremor of the hands when extended. This occurs due to impaired ammonia metabolism in the liver leading to neurotoxicity. Jaundice (B) is a sign of liver dysfunction but not specific to hepatic encephalopathy. Ascites (C) is the accumulation of fluid in the peritoneal cavity, common in liver cirrhosis but not indicative of hepatic encephalopathy. Splenomegaly (D) is enlargement of the spleen, which can occur in cirrhosis but is not a direct sign of hepatic encephalopathy.
A healthcare provider is preparing to administer a scheduled dose of intravenous (IV) metoprolol (Lopressor) to a client. The client's apical pulse is 58 beats/minute. What action should the healthcare provider take?
- A. Administer the medication as prescribed.
- B. Hold the medication and notify the healthcare provider.
- C. Give half the prescribed dose and recheck the pulse in 30 minutes.
- D. Administer the medication and then recheck the pulse in 30 minutes.
Correct Answer: B
Rationale: The correct answer is B: Hold the medication and notify the healthcare provider. The rationale is that metoprolol is a beta-blocker that can further decrease heart rate. With a low apical pulse of 58 beats/minute, administering metoprolol can potentially cause bradycardia or further slow down the heart rate to dangerous levels. Holding the medication and notifying the healthcare provider allows for further assessment and potential adjustment of the dosage or consideration of alternative treatments.
Incorrect choices:
A: Administering the medication as prescribed can lead to bradycardia and potential harm to the client.
C: Giving half the prescribed dose and rechecking the pulse in 30 minutes can still lead to further bradycardia and potential harm.
D: Administering the medication and then rechecking the pulse in 30 minutes is not appropriate as the initial pulse rate is already low, and waiting to recheck could lead to adverse effects before intervention.
Which assessment finding indicates a client's readiness to leave the nursing unit for a bronchoscopy?
- A. Client denies allergies to contrast media.
- B. Skin prep to insertion site completed.
- C. On-call sedation administered.
- D. Oxygen at 2 L/minute via nasal cannula.
Correct Answer: C
Rationale: Rationale: Option C, on-call sedation administered, is the correct answer because sedation is essential for bronchoscopy to ensure the client is comfortable and cooperative during the procedure. Sedation helps reduce anxiety and discomfort, making the procedure more tolerable. Options A, B, and D are incorrect as they do not directly indicate readiness for the procedure. Denying allergies to contrast media (A) is important but not specific to bronchoscopy readiness. Skin prep completion (B) is part of the pre-procedure preparation but does not confirm readiness. Oxygen administration (D) is a routine care measure and does not indicate readiness for bronchoscopy.
The client has received 250 ml of 0.9% normal saline through the IV line in the last hour. The client is now tachypneic and has a pulse rate of 120 beats/minute, with a pulse volume of +4. In addition to reporting the assessment findings to the healthcare provider, what action should the nurse implement?
- A. Discontinue the IV and apply pressure at the site.
- B. Decrease the saline to a keep-open rate.
- C. Increase the rate of the current IV solution.
- D. Change the IV fluid to 0.45% normal saline at the same rate.
Correct Answer: B
Rationale: The correct answer is B: Decrease the saline to a keep-open rate. The client is showing signs of fluid overload, indicated by tachypnea and bounding pulse. By decreasing the saline to a keep-open rate, the nurse can prevent further fluid overload while maintaining IV access. Discontinuing the IV and applying pressure (choice A) is not necessary unless there is a specific issue with the IV site. Increasing the rate of the current IV solution (choice C) would worsen the fluid overload. Changing the IV fluid to 0.45% normal saline (choice D) at the same rate may not effectively address the fluid overload concern.
The healthcare provider is caring for a client with a chest tube. Which assessment finding requires immediate intervention?
- A. Intermittent bubbling in the water seal chamber.
- B. Drainage of 75 ml in the first hour post-insertion.
- C. Crepitus around the insertion site.
- D. Fluctuation of the water level in the water seal chamber with respiration.
Correct Answer: C
Rationale: The correct answer is C: Crepitus around the insertion site. Crepitus suggests subcutaneous emphysema, which can indicate a pneumothorax or air leak. Immediate intervention is needed to prevent further complications.
A: Intermittent bubbling in the water seal chamber is expected and indicates a functioning chest tube system.
B: Drainage of 75 ml in the first hour post-insertion is within the normal range and should be monitored.
D: Fluctuation of the water level in the water seal chamber with respiration is a normal finding indicating the chest tube is functioning correctly.