Extract:

Question 1 of 5

The nurse is caring for a client who has just undergone a mastectomy. Which of the following interventions is most important in the immediate postoperative period?

Correct Answer: A

Rationale: Encouraging arm exercises prevents lymphedema and promotes circulation post-mastectomy.

Question 2 of 5

A client has been defibrillated at 360 joules (monophasic) and the attempts to convert the ventricular fibrillation (VF) were unsuccessful. Based on an evaluation of the situation, the nurse determines that which action is best?

A. Terminating the resuscitation effort B. Preparing for the administration of sodium bicarbonate intravenously C. Performing cardiopulmonary resuscitation (CPR) for 5 cycles or about 2 minutes D. Performing CPR for 5 minutes, then defibrillating 3 more times at 400 joules

Correct Answer: C

Rationale: Defibrillation is an asynchronous countershock used to terminate pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF). The defibrillator is charged to 120 to 200 joules (biphasic) or 300 joules (monophasic) for 1 countershock from the defibrillator, and then CPR is immediately resumed and continued for 5 cycles or about 2 minutes. The rhythm is reassessed after 2 minutes and if VF or pulseless VT continues, the defibrillator is charged to give a second shock at the same energy level previously used. CPR is resumed after the shock if needed and the life support protocol is continued. There is no information in the question to indicate that life support should be terminated. Sodium bicarbonate may be prescribed but is not the best action. Giving CPR for 5 minutes may not help oxygenation to the brain and myocardium and is not the best action.

Question 3 of 5

The nurse is caring for a client with a fracture of a long bone. Which of the following assessments would be the earliest symptom of a fat embolism?

A. Respiratory distress. B. Confusion. C. Petechiae. D. Fever.

Correct Answer: A

Rationale: Respiratory distress is the earliest symptom of fat embolism syndrome, as emboli obstruct pulmonary circulation, leading to hypoxia.

Question 4 of 5

The nurse teaches a client taking desmopressin (DDAVP) nasal spray about how to manage treatment. The nurse determines that the client needs additional instruction when he makes which of the following comments?

A. I should check for sores in my nose while taking this medication.' B. I should use the same nostril each time I take the medicine.' C. I should report nasal congestion.' D. I should report any signs of respiratory infection.'

Correct Answer: B

Rationale: Using the same nostril each time can cause irritation or reduced efficacy; alternating nostrils is recommended. The other comments reflect correct understanding of desmopressin use.

Question 5 of 5

The Joint Commission on the Accreditation of Healthcare Organizations mandates standardized 'hand off' change of shift reporting. Which of the following is a standardized 'hand off' change of shift reporting system that you may want to consider for implementation on your nursing care unit?

A. The Four P's B. UBAR C. ISBAR D. MAUMAR

Correct Answer: C

Rationale: ISBAR is a standardized hand-off reporting system (Introduction, Situation, Background, Assessment, Recommendation) recommended by The Joint Commission for effective communication during shift changes.