A nurse is checking the vital signs of a 92-year old patient. The patient's radial pulse has an irregular beat about every 5th or 6th beat. The rate is 92 /min. The patient is asymptomatic. What should be the first intervention?

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Question 1 of 5

A nurse is checking the vital signs of a 92-year old patient. The patient's radial pulse has an irregular beat about every 5th or 6th beat. The rate is 92 /min. The patient is asymptomatic. What should be the first intervention?

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 2 of 5

Which of the following organizations has established standards for clinical nursing practice?

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 3 of 5

Following death, rigor mortis sets in after:

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 4 of 5

What are the first nursing actions of the nurse when a male client is admitted to the emergency department following an accident?

Correct Answer: A

Rationale: The correct answer is A because the first priority in emergency nursing is to assess the client's airway, breathing, circulation, and neurological response (ABCs). This approach ensures that life-threatening issues are addressed first. Checking respiration, circulation, and neurological response provides essential information on the client's immediate condition and guides further interventions. Choice B is incorrect because assessing the level of consciousness alone does not cover all critical aspects of the client's condition. Choice C is incorrect as checking pupils does not address the client's overall status comprehensively. Choice D is incorrect because stabilizing the spine should only be done after assessing the ABCs to ensure the client's immediate needs are met.

Question 5 of 5

Which factor is most relevant to the administration of lidocaine I.V. to a male client?

Correct Answer: C

Rationale: The correct answer is C: Presence of premature ventricular contractions (PVCs) on a cardiac monitor. Lidocaine is commonly used to treat PVCs as it is a Class 1B antiarrhythmic agent that stabilizes cell membranes in the heart, reducing the automaticity of ectopic pacemaker cells. PVCs can be a precursor to more serious arrhythmias, so addressing them promptly is crucial. A: Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter - Not directly related to the administration of lidocaine. B: Increase in systemic blood pressure - Lidocaine typically has minimal effects on systemic blood pressure, and this is not a primary consideration when administering it. D: Increase in intracranial pressure (ICP) - Lidocaine is not commonly associated with increasing ICP, so this is not a primary concern.

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