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Questions 164

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Extract:


Question 1 of 5

A client with an implantable cardioverter defibrillator (ICD) develops ventricular tachycardia (VT) with a pulse while admitted to the medical-surgical unit. The ICD fires multiple times without successfully stopping the VT, causing the client to become confused and difficult to rouse. Which action by the nurse is appropriate?

Correct Answer: D

Rationale: Persistent VT causing altered mental status requires synchronized cardioversion to restore normal rhythm.

Question 2 of 5

The pediatric nurse receives report on 4 clients. Which client should the nurse see first?

Correct Answer: B

Rationale: The 6-year-old post-bronchoscopy is at risk for airway complications and requires immediate assessment.

Question 3 of 5

The nurse is performing tracheal suctioning and notes a previously used bottle of saline at the client's bedside. The nurse should:

Correct Answer: B

Rationale: A new, sterile saline bottle is required for suctioning to prevent infection. Reusing or relabeling an opened bottle is unsafe.

Question 4 of 5

The nurse is monitoring a 12-month-old diagnosed with intussusception. Which findings should the nurse expect? Select all that apply.

Correct Answer: B,D,E

Rationale: Intussusception is characterized by a sausage-shaped mass, paroxysmal pain with knee-drawing, and 'currant jelly' stools.

Question 5 of 5

Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing

Correct Answer: D

Rationale: Clients with chronic obstructive pulmonary disease have difficulty exhaling fully as a result of weak alveolar walls. Alveolar collapse can be avoided with the use of pursed-lip breathing.

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