Concepts for Nursing Practice Test Bank

Questions 14

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Concepts for Nursing Practice Test Bank Questions

Question 1 of 5

A nurse working in the emergency department is participating in the resuscitation of a client experiencing sudden cardiac death. After five cycles of CPR, the nurse evaluates the client's cardiac rhythm as asystole. What is the next action by the nurse?

Correct Answer: B

Rationale: Asystole is the absence of any cardiac electrical activity, and it is a non-shockable rhythm. In the case of asystole, defibrillation would not be effective. The next appropriate action would be to continue high-quality CPR and administer epinephrine according to the advanced cardiac life support (ACLS) protocol. Additionally, assessing the client's pulse is crucial to determine if there is any return of spontaneous circulation (ROSC) following CPR and medication administration. Checking the cardiac monitor electrodes ensures proper attachment and accurate monitoring of the client's cardiac rhythm but may not directly impact the management of asystole.

Question 2 of 5

The nurse identifies assessment findings for a client with preeclampsia. Blood pressure is 158/100 mmHg; urinary output 50 mL/hour; crackles in the lungs on auscultation; urine protein 1+; 1+ edema hands, feet, ankles. On the next hourly assessment, which new assessment finding would indicate worsening of the condition?

Correct Answer: B

Rationale: A decreased urinary output from 50 mL/hour to 40 mL/hour indicates a worsening of the client's condition with preeclampsia. A decreased urinary output can be a sign of reduced kidney function, which is a serious complication in preeclampsia. Monitoring urinary output is crucial in assessing kidney function and overall fluid balance in clients with preeclampsia. It is important to promptly address any reduction in urinary output to prevent further deterioration in the client's condition. The other options do not specifically indicate a worsening of the condition in this context.

Question 3 of 5

The nurse is evaluating the teaching provided to a patient with acute glomerulonephritis. Which patient action indicates that additional teaching is not necessary?

Correct Answer: B

Rationale: Option B, "Demonstrates care of the vascular access device for dialysis," indicates that the patient understands how to care for their vascular access device, which is important for receiving dialysis treatment. This action shows adequate comprehension and competency in managing this aspect of their care. Therefore, additional teaching is not necessary in this area. On the other hand, options A, C, and D present actions that may require further clarification or reinforcement in the teaching provided to the patient with acute glomerulonephritis.

Question 4 of 5

The nurse is conducting a health history with a patient that focuses on the endocrine system. Which question should the nurse include in this assessment?

Correct Answer: B

Rationale: The nurse should include the question "Have you noticed a change in your thirst?" in the health history focusing on the endocrine system because changes in thirst can be indicative of conditions such as diabetes insipidus or diabetes mellitus that affect the endocrine system. Thirst can be altered due to changes in hormone levels, particularly those related to water balance and blood sugar regulation. Monitoring changes in thirst can provide important information about potential endocrine imbalances in the body. Asking about changes in thirst is relevant to assessing the patient's endocrine health in this context.

Question 5 of 5

A nurse working in the emergency department is participating in the resuscitation of a client experiencing sudden cardiac death. After five cycles of CPR, the nurse evaluates the client's cardiac rhythm as asystole. What is the next action by the nurse?

Correct Answer: B

Rationale: Asystole is the absence of any cardiac electrical activity, and it is a non-shockable rhythm. In the case of asystole, defibrillation would not be effective. The next appropriate action would be to continue high-quality CPR and administer epinephrine according to the advanced cardiac life support (ACLS) protocol. Additionally, assessing the client's pulse is crucial to determine if there is any return of spontaneous circulation (ROSC) following CPR and medication administration. Checking the cardiac monitor electrodes ensures proper attachment and accurate monitoring of the client's cardiac rhythm but may not directly impact the management of asystole.

Similar Questions

A nurse working in the emergency department is participating in the resuscitation of a client experiencing sudden cardiac death. After five cycles of CPR, the nurse evaluates the client's cardiac rhythm as asystole. What is the next action by the nurse?
The client's vital signs include P 119, R 24, BP 98/63, T 1�F, and SpO2 89%. Which actions would the nurse implement at this time? Select all that apply.
A client diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea. Which is the priority nursing diagnosis for this client?
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The nurse is preparing to conduct a cardiac assessment for a pediatric client. Which location will the nurse use when auscultating the apical pulse?

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