EXAM 2024-2025 ACTUAL EXAM COMPLETE 100
QUESTIONS AND CORRECT DETAILED ANSWERS
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Terms in this set (41)
,A client develops Initiate defibrillation
ventricular fibrillation in a
coronary care unit. Which Ventricular fibrillation is a lethal dysrhythmia and,
action is priority? once identified, must be terminated immediately by
defibrillation so the sinus node can act again as the
heart's pacemaker. Oxygen is administered to correct
Administer oxygen hypoxia, but if the heart is not pumping, oxygen will
not be delivered to the tissues; it does not take
Initiate defibrillation priority over defibrillation. Cardioversion is not
effective in ventricular fibrillation. Bicarbonate is
Initiate cardioversion administered to correct acidosis; it does not take
priority over defibrillation.
Administer sodium
bicarbonate intravenously
A client is diagnosed with Avoid traumatic injury and exposure to infection.
pancytopenia caused by
chemotherapy. What Reduced platelets increase the likelihood of
should a nurse teach the uncontrolled bleeding; reduced lymphocytes
client about this increase the susceptibility to infection. Beginning a
complication? program of meticulous mouth care is helpful for
stomatitis, not pancytopenia; aggressive oral hygiene
may precipitate bleeding from the gums. Although
Begin a program of fluids may be increased to flush out the toxic
meticulous mouth care. byproducts of chemotherapy, this will have no effect
on pancytopenia. Unusual muscle cramps or tingling
Avoid traumatic injury and sensations in the extremities are signs of
exposure to infection. hypocalcemia and do not apply to pancytopenia.
Increase oral fluid intake
to at least 3 L/day.
Report unusual muscle
cramps or tingling
sensations in the
extremities.
,A client who has had a Decreased force of contraction
myocardial infarction
experiences a noticeably A direct relationship exists between systolic blood
decreased pulse pressure. pressure and the force of left ventricular contraction.
What does this indicate to A decreased pulse pressure is associated with heart
the nurse? failure or hypovolemia. A decreased blood volume is
indicated by a decreased pulse pressure.
Hyperactivity of the heart is indicated by dysrhythmias
Increased blood volume and tachycardia. A decreased pulse pressure indicates
decreased cardiac sufficiency.
Hyperactivity of the heart
Increased cardiac
sufficiency
Decreased force of
contraction
A client is admitted to the -Bradycardia
emergency department -Hypotension
with the diagnosis of a -Bladder dysfunction
possible spinal cord injury.
The nurse should monitor
the client for what clinical
manifestations of spinal
shock?
Bradycardia
Hypotension
Spastic paralysis
Bladder dysfunction
Increased pulse pressure
, A client who lives with the State that that the client seems anxious and ask
parents is diagnosed with whether the client would like to talk for a while.
stage III Hodgkin disease
with a grossly involved Stating that the client seems anxious and asking
spleen and is scheduled whether the client would like to talk for a while
for a splenectomy. After provides an opportunity for the client to explore
the nurse performs concerns with the nurse. The data do not indicate
preoperative teaching, the regression; the client is anxious, not regressed. If the
client appears anxious. nurse considers the response an unconscious
What is the best approach response relating to the client's relationship with the
for the nurse to use at this parents, this is based on an incorrect interpretation of
time? the data. The data do not indicate that the client does
not understand; the nurse should attempt to provide
for consensual validation before coming to this
Allow the client to regress conclusion.
at this time and rest
quietly.
State that that the client
seems anxious and ask
whether the client would
like to talk for a while.
Consider the reaction an
unconscious response and
inquire about the client's
relationship with the
parents.
Understand that anxiety
prevented the client from
comprehending and
repeat the information in
simpler terms.