Nokea
Which statement about automated external defibrillators is accurate?
- A. They are not as effective as regular defibrillators.
- B. They are replacing regular defibrillators in acute care settings.
- C. Only BLS certified people in the community should use them.
- D. They can be easily used by people with no healthcare experience.
Correct Answer: D
Rationale: AEDs are designed for use by laypersons with minimal training, making them accessible for public use in emergencies.
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The nurse should assess the child with nephrotic syndrome for which of the following? Select all that apply.
- A. Normal blood pressure.
- B. Generalized edema.
- C. Normal serum lipid levels.
- D. No red blood cells in the urine.
- E. Elevated streptococcal antibody titers.
Correct Answer: B,D
Rationale: Nephrotic syndrome is characterized by generalized edema and no red blood cells in the urine. Blood pressure may be elevated, serum lipids are typically high, and streptococcal antibodies are not typically associated.
You are caring for a client at the end of life. The client tells you that they are grateful for having considered and decided upon some end of life decisions and the appointments of those who they wish to make decisions for them when they are no longer able to do so. During this discussion with the client and the client's wife, the client states that 'my wife and I are legally married so I am so glad that she can automatically make all healthcare decisions on my behalf without a legal durable power of attorney when I am no longer able to do so myself' and the wife responds to this statement with, 'that is not completely true. I can only make decisions for you and on your behalf when these decisions are not already documented on your advance directive.' How should you, as the nurse, respond to and address this conversation between the husband and wife and the end of life?
- A. You should respond to the couple by stating that only unanticipated treatments and procedures that are not included in the advance directive can be made by the legally appointed durable power of attorney for healthcare decisions.
- B. You should be aware of the fact that the wife of the client has a knowledge deficit relating to advance directives and durable powers of attorney for healthcare decisions and plan an educational activity to meet this learning need.
- C. You should be aware of the fact that the client has a knowledge deficit relating to advance directives and durable powers of attorney for healthcare decisions and plan an educational activity to meet this learning need.
- D. You should reinforce the wife's belief that legally married spouses automatically serve for the other spouse's durable power of attorney for health care decisions and that others than the spouse cannot be legally appointed while people are married
Correct Answer: C
Rationale: The client's statement reflects a misunderstanding that a spouse automatically assumes the role of durable power of attorney for healthcare decisions without a legal designation. The wife's response is correct in that an advance directive takes precedence, and a durable power of attorney is only effective for decisions not covered by the advance directive. The nurse should recognize the client's knowledge deficit and plan education to clarify the roles of advance directives and durable power of attorney, as stated in option C.
The nurse is teaching a client with gout about dietary management. Which of the following foods should the client avoid?
- A. Spinach.
- B. Cherries.
- C. Organ meats.
- D. Whole grains.
Correct Answer: C
Rationale: Organ meats are high in purines, which increase uric acid levels and should be avoided in gout.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is receiving oxygen therapy. Which of the following flow rates is most appropriate for this client?
- A. 1-2 L/min via nasal cannula.
- B. 4-6 L/min via face mask.
- C. 8-10 L/min via non-rebreather mask.
- D. 12-15 L/min via Venturi mask.
Correct Answer: A
Rationale: A flow rate of 1-2 L/min via nasal cannula is appropriate for COPD clients to avoid suppressing their hypoxic respiratory drive.
A client with a diagnosis of acquired immunodeficiency syndrome and cytomegalovirus retinitis is receiving ganciclovir. Which action should the nurse plan to take while the client is taking this medication?
- A. Monitor blood glucose levels for elevation.
- B. Administer the medication on an empty stomach only.
- C. Apply pressure to venipuncture sites for at least 2 minutes.
- D. Provide the client with a soft toothbrush and an electric razor.
Correct Answer: D
Rationale: Ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects. For this reason, the nurse monitors the client for signs and symptoms of bleeding and implements the same precautions that are used for a client receiving anticoagulant therapy. These include providing a soft toothbrush and electric razor to minimize the risk of trauma that could result in bleeding. The medication may cause hypoglycemia, not hyperglycemia. The medication does not have to be taken on an empty stomach. Venipuncture sites should be held for approximately 10 minutes.