Unintentional Injury Violence Mobility Sensory Perception Perfusion Fluid and Electrolytes Med-Surg IV Deltech Stanton Nursing

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Sample questions from Unintentional Injury Violence Mobility Sensory Perception Perfusion Fluid and Electrolytes Med-Surg IV Deltech Stanton Nursing

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.In the emergency department, a 16-year-old with a repaired congenital heart defect reports sudden palpitations and dizziness during track practice. The monitor shows a regular narrow-complex tachycardia at 190/min, and the client is alert with a blood pressure of 104/66 mm Hg. Which action should the nurse take first?

   • A.Assist the client to perform a vagal maneuver as prescribed by protocol.
   • B.Administer an IV fluid bolus rapidly.
   • C.Encourage the client to cough forcefully and ambulate.
   • D.Prepare for immediate synchronized cardioversion.

   Rationale: A stable client with a regular narrow-complex tachycardia may first be treated with a vagal maneuver, which can increase vagal tone and slow AV-node conduction. Synchronized cardioversion is indicated if the client becomes hemodynamically unstable or does not respond to initial measures. A rapid fluid bolus is not the first intervention without evidence of hypovolemia, and ambulation is unsafe while the client is dizzy and tachycardic.

2. 2.A client states, 'My legs feel heavy when I walk, but the pain goes away when I stop.' The client has diminished pedal pulses and cool feet. Which teaching is most appropriate?

   • A.Avoid walking so the legs do not require additional oxygen.
   • B.Keep the legs elevated above the heart whenever sitting.
   • C.Walk until moderate discomfort occurs, rest until it resolves, and then resume walking.
   • D.Apply a heating pad to the feet before each walk.

   Rationale: Intermittent claudication is caused by inadequate arterial blood flow during activity, and a structured walking program can improve functional distance over time. Elevating the legs above the heart can further reduce arterial perfusion; dependent positioning may be more comfortable. Heating pads risk burns in poorly perfused extremities, and avoiding all walking does not promote collateral circulation or improved activity tolerance.

3. 3.Refer to the client's chart. Which findings require the nurse to take immediate action for worsening cardiac perfusion? Select all that apply.

   • A.The client reports new chest pressure at 1000.
   • B.The heart rate decreased from 96/min to 84/min while the client remained alert.
   • C.The urine output is 15 mL during the hour ending at 1000.
   • D.The blood pressure has fallen from 118/72 to 88/54 mm Hg.
   • E.The client has warm skin and a capillary refill of 2 seconds at 0800.

   Rationale: New chest pressure, a falling blood pressure, and urine output of only 15 mL in an hour are concerning for impaired cardiac output and tissue perfusion; the chart shows a decline in blood pressure from 118/72 to 88/54 mm Hg. Warm skin with a 2-second capillary refill at 0800 is not evidence of poor peripheral perfusion at that time. A heart rate decrease to 84/min is not concerning by itself when the client remains alert.

4. 4.The provider prescribes digoxin for a 10-month-old with heart failure. Before administering the dose, which finding should prompt the nurse to withhold the medication and notify the provider?

   • A.Respiratory rate of 30/min while calm
   • B.Oxygen saturation of 97% on room air
   • C.One wet diaper in the past 3 hours
   • D.Apical heart rate of 88/min while the infant is asleep

   Answer and rationale are in the full material.

5. 5.During a home visit, a 72-year-old who takes warfarin for atrial fibrillation says, 'I started taking an over-the-counter pain medicine every day.' Which medication use should the nurse identify as the greatest concern?

   • A.Taking a daily multivitamin without vitamin K
   • B.Taking ibuprofen for knee pain
   • C.Taking acetaminophen at the prescribed dose
   • D.Using saline nasal spray for congestion

   Answer and rationale are in the full material.