Nursing Elites

1. After a client with an Automated Internal Cardiac Defibrillator (AICD) is successfully defibrillated for Ventricular Fibrillation (VF), what should the nurse do next?

• A. Go to the client to assess for signs and symptoms of decreased cardiac output.
• B. Call the physician to inform them of the VF episode for medication adjustments.
• C. Call the 'on-call' person in the cath lab to re-charge the ICD in case of a recurrence.
• D. Document the incident on the code report form and follow up regularly.

Correct answer: A

Rationale: After a client is successfully defibrillated, the immediate priority is to assess the client for signs and symptoms of decreased cardiac output, such as altered level of consciousness, chest pain, shortness of breath, or hypotension. This assessment is crucial to determine the effectiveness of the defibrillation and the client's current hemodynamic status. Calling the physician for medication adjustments without assessing the client first could delay essential interventions. Contacting the 'on-call' person in the cath lab to re-charge the ICD is not the initial action needed after successful defibrillation. Documenting the incident is important but should not take precedence over assessing the client's immediate condition.

2. The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate that the client should not be advanced to the next level?

• A. Facial flushing
• B. A complaint of chest heaviness
• C. Heart rate increase of 10 beats/min
• D. Systolic blood pressure increase of 10 mm Hg

Correct answer: B

Rationale: The correct answer is a complaint of chest heaviness. Onset of chest pain indicates myocardial ischemia, which can be life-threatening. Chest pain in a client post-myocardial infarction should be promptly evaluated, and the activity level should not be advanced. Choices A, C, and D are not the best options because facial flushing, a heart rate increase of 10 beats/min, and a systolic blood pressure increase of 10 mm Hg are not typical indicators of myocardial ischemia or necessarily contraindications for advancing activity levels in this context.

3. A client, age 28, was recently diagnosed with Hodgkin's disease. After staging, therapy is planned to include combination radiation therapy and systemic chemotherapy with MOPP"?nitrogen mustard, vincristine (Onconvin), prednisone, and procarbazine. In planning care for this client, the nurse should anticipate which of the following side effects to contribute to a sense of altered body image?

• A. Cushingoid appearance
• B. Alopecia
• C. Temporary or permanent sterility
• D. Pathologic fractures

Correct answer: B

Rationale: The correct answer is B: Alopecia. Chemotherapy drugs like vincristine can cause alopecia, which is hair loss. This side effect can significantly impact a patient's body image. While Cushingoid appearance (A) can be a side effect of long-term steroid use, temporary or permanent sterility (C) may affect a patient's future fertility but not necessarily alter body image. Pathologic fractures (D) are not common side effects of Hodgkin's disease or its treatment and do not directly contribute to a sense of altered body image in the same way as alopecia does.

4. Which of the following goals is the most important for the nurse to address for a client admitted to the cardiac rehabilitation unit?

• A. Reduction of anxiety
• B. Referral to community resources
• C. Identification of lifestyle changes
• D. Verbalization of energy-conservation techniques

Correct answer: C

Rationale: The most important goal for a client admitted to the cardiac rehabilitation unit is the identification of lifestyle changes. This is crucial in promoting cardiovascular health and preventing future cardiac issues. Lifestyle changes such as diet modifications, exercise routines, smoking cessation, and stress management play a significant role in improving the overall cardiovascular well-being of the patient. While reducing anxiety, referring to community resources, and verbalizing energy-conservation techniques are all important aspects of care, identifying lifestyle changes is the primary focus in helping the client achieve long-term cardiovascular wellness.

5. Teaching about the importance of avoiding foods high in potassium is most crucial for which client?

• A. a client receiving diuretic therapy
• B. a client with an ileostomy
• C. a client with metabolic alkalosis
• D. a client with renal disease

Correct answer: D

Rationale: Clients with renal disease are prone to hyperkalemia due to impaired kidney function, making it crucial for them to avoid foods high in potassium to prevent further complications. Choices A, B, and C are incorrect because clients receiving diuretic therapy, with an ileostomy, or with metabolic alkalosis are at risk of hypokalemia. These individuals should actually consume foods high in potassium to replenish the electrolyte lost through diuresis, ileostomy output, or metabolic alkalosis.

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