Nokea
Which intervention should the nurse implement when defibrillating a client who is in ventricular fibrillation?
- A. Defibrillate the client at 50, 100, and 200 joules.
- B. Do not remove the oxygen source during defibrillation.
- C. Place petroleum jelly on the defibrillator pads.
- D. Shout 'all clear' prior to defibrillating the client.
Correct Answer: D
Rationale: Shouting 'all clear' (D) ensures safety before defibrillation. Energy levels (A) are 200–360 joules, oxygen (B) is removed to prevent fire, and petroleum jelly (C) is not used.
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The 45-year-old male client diagnosed with essential hypertension has decided not to take his medications. The client's BP is 178/94, indicating a perfusion issue. Which question should the nurse ask the client first?
- A. Do you have the money to buy your medication?'
- B. Does the medication give unwanted side effects?'
- C. Did you quit taking the medications because you don’t feel bad?'
- D. Can you tell me why you stopped taking the medication?'
Correct Answer: D
Rationale: Asking why the client stopped (D) is open-ended, identifying barriers like side effects (B) or asymptomatic disease (C). Financial issues (A) are secondary.
The intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement?
- A. Notify the health-care provider immediately.
- B. Elevate the head of the client's bed.
- C. Document this as a normal and expected finding.
- D. Administer morphine intravenously.
Correct Answer: A
Rationale: An S3 heart sound post-MI (A) indicates heart failure, requiring HCP notification. Elevating HOB (B) is supportive, documenting as normal (C) is incorrect, and morphine (D) is for pain.
Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease?
- A. Assess the client's radial pulse.
- B. Assess the client's serum potassium level.
- C. Assess the client's glucometer reading.
- D. Assess the client's pulse oximeter reading.
Correct Answer: B
Rationale: Loop diuretics cause hypokalemia, which can precipitate dysrhythmias in CAD. Assessing potassium (B) is critical. Pulse (A), glucose (C), and SpO2 (D) are less directly related.
The client diagnosed with a myocardial infarction asks the nurse, 'Why do I have to rest and take it easy? My chest doesn’t hurt anymore.' Which statement would be the nurse’s best response?
- A. Your heart is damaged and needs about four (4) to six (6) weeks to heal.'
- B. There is necrotic myocardial tissue that puts you at risk for dysrhythmias.'
- C. Your doctor has ordered bedrest. Therefore, you must stay in the bed.'
- D. Just because your chest doesn’t hurt anymore doesn’t mean you are out of danger.'
Correct Answer: A
Rationale: Explaining that the heart needs 4–6 weeks to heal (A) is accurate and understandable. Necrosis/dysrhythmias (B) is technical, doctor’s orders (C) dismiss patient autonomy, and danger (D) is vague.
The nurse is caring for a client diagnosed with coronary artery disease (CAD). Which should the nurse teach the client prior to discharge?
- A. Carry your nitroglycerin tablets in a brown bottle.
- B. Swallow a nitroglycerin tablet at the first sign of angina.
- C. If one nitroglycerin tablet does not work in 10 minutes, take another.
- D. Nitroglycerin tablets have a fruity odor if they are potent.
Correct Answer: A
Rationale: Nitroglycerin should be stored in a dark bottle (A) to maintain potency. Swallowing (B) is incorrect (sublingual), 10 minutes (C) should be 5, and fruity odor (D) is not a potency indicator.