A+. REAL EXAM QUESTIONS FOR YOUR COMING EXAM 2023
The nurse notes the presence of a P wave, QRS complex, flattened T
waves, and occasional U waves on a client's cardiac monitor screen.
Fill in the correct missing information by choosing from the lists of
options in the drop-down menus.
The nurse should suspect
Your Answer: hypokalemiaCorrect Answer: hypokalemia
because of the
Your Answer: flattened T waves and occasional U wavesCorrect
Answer: flattened T waves and occasional U waves
Rationale:Cardiac changes in hypokalemia include impaired
repolarization, resulting in a flattening of the T wave and eventually
the emergence of a U wave. Therefore, the nurse should suspect
hypokalemia. The incidence of potentially lethal ventricular
dysrhythmias is increased in hypokalemia. The nurse should
immediately assess the client's vital signs and cardiac status for
signs of hypokalemia. The nurse should also check the client's most
recent serum potassium level and then contact the primary health
care provider to report the findings and obtain prescriptions to
treat the hypokalemic state.
The nurse is preparing a client for a chest x-ray and notes that the
client is wearing a religious medal on a chain around the neck.
What should the nurse do with regard to this personal item? Click
to highlight the correct answer from the options provided.
,The nurse should: (Select 1 option)
✓Ask the client if the chain and medal can be removed during the
procedure.
Because: (Select 1 option)
✓The chain and medal may have cultural significance.
Rationale:Before certain diagnostic procedures, it is typical to have
a client remove personal objects that are worn on the body
because of client safety and the possibility of compromising test
results. Therefore, the nurse should ask the client about the
significance of such an item and its removal because it may have
cultural or spiritual significance. If so, the nurse should ask the
client if the item can be either removed temporarily or placed on
another part of the body during the procedure if appropriate.
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While preparing a client for surgery scheduled in 1 hour, the client
states to the nurse: "I have changed my mind. I don't want this
surgery." Click to highlight the correct answer from the options
provided.
The nurse should: (Select 1 option)
Cancel the surgery.
Contact the surgeon.
✓Discuss the client's concerns.
,Call the identified support person.
Because: (Select 1 option)
Client consent is required prior to any procedure.
✓Further questions or concerns should be determined and
addressed.
Ethical considerations are important for a client undergoing
surgery.
The nursing scope of practice places limitations on how the nurse
can respond.
Rationale:If the client indicates that he or she does not want a
prescribed therapy, treatment, or procedure such as surgery, the
nurse should further investigate the client's request. If the client
indicates that he or she has changed his or her mind about surgery,
the nurse should assess the client and explore with the client his or
her concerns about not wanting the surgery. The nurse would then
withhold further surgical preparation and contact the surgeon to
report the client's request so that the surgeon can discuss the
consequences of not having the surgery with the client. Further
assessment and follow-up related to the client's request need to be
done. It is the client's right to refuse treatment; however, further
investigation is needed so the interventions can be tailored to
specific needs.
The nurse notes that there has been an increase in the number of
intravenous (IV) site infections that developed in the clients being
cared for on the nursing unit. How should the nurse proceed to
, implement a quality improvement program?For each action, click
to specify whether the action would be:
Indicated: an action that the nurse should take to resolve the
problem
Non-essential: an action that the nurse could take without harming
the client, but the action would not be likely to address the
problem
Contraindicated: an action that could harm the client and should
not be taken
Collect identifying patient information
Contraindicated
Note the mental status of the client
Non-essential
Note primary and secondary diagnoses of clients affected
Indicated
Note the type of IV catheter used
Indicated
Note the type of IV site dressings being used
Indicated
Note the medication types being infused
Non-essential
Note frequency of assessments of IV sites
Indicated
Note the expected duration of the IV site
Non-essential