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Which of the following statements should the nurse include when teaching a community health course on adult cardiopulmonary resuscitation (CPR)? Select all that apply.
- A. The compression rate is 100 to 120 per minute.
- B. The compression depth should be 1.5 inches.
- C. Allow full chest recoil between compressions.
- D. Rotate compressor at least every 2 minutes.
- E. Stop to check your pulse every 30 seconds.
Correct Answer: A,C,D
Rationale: Compression rate of 100-120/min ensures adequate circulation. B: Incorrect - Depth should be 2-2.4 inches in adults. C: Correct - Full chest recoil maximizes venous return. D: Correct - Rotating compressors prevents fatigue. E: Incorrect - Pulse checks are done after rhythm checks, not every 30 seconds.
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The nurse is caring for a client with congestive heart failure (CHF). The nurse should anticipate a prescription for which medication?
- A. Enalapril
- B. Verapamil
- C. Lovastatin
- D. Gemfibrozil
Correct Answer: A
Rationale: Enalapril, an ACE inhibitor, reduces afterload and preload in CHF, improving cardiac function.
Which of the following actions should the nurse take for a client immediately postoperative following a coronary artery bypass graft surgery (CABG)? Select all that apply.
- A. Obtain the client's capillary blood glucose
- B. Provide tracheostomy care, as needed
- C. Teach the client about the driving restrictions after this procedure
- D. Ground the epicardial pacing wires to the pacemaker generator
- E. Ensure patency of the mediastinal chest tubes
Correct Answer: A,D,E
Rationale: Monitoring blood glucose is crucial, especially in clients with diabetes or stress-induced hyperglycemia post-CABG. B: Incorrect - Tracheostomy care is not typically required unless the client has a tracheostomy, which is not indicated here. C: Incorrect - Teaching about driving restrictions is important but not an immediate postoperative priority. D: Correct - Grounding epicardial pacing wires ensures proper pacemaker function if temporary pacing is needed. E: Correct - Ensuring mediastinal chest tube patency prevents complications like tamponade or hemothorax.
Which of the following teaching topics should the nurse prioritize when educating staff about caring for a client with a pacemaker? Select all that apply.
- A. Understanding the indications for pacemaker placement.
- B. Recognizing signs of pacemaker malfunction.
- C. Explaining different types of pacemakers and how they function.
- D. Advising clients with pacemakers to avoid all sources of electromagnetic fields (EMFs).
- E. Discussing the importance of regular pacemaker check-ups and follow-up care.
- F. Providing guidelines on safe physical activities and exercise after pacemaker placement
Correct Answer: A,B,C,E,F
Rationale: Understanding indications helps staff anticipate client needs. Recognizing malfunction signs ensures timely intervention. C: Correct - Knowing pacemaker types aids in proper care. D: Incorrect - Avoiding all EMFs is overly restrictive; modern pacemakers are shielded. E: Correct - Regular check-ups ensure device functionality. F: Correct - Safe activity guidelines prevent complications.
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.
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.