A client who was admitted with rapid atrial flutter is receiving amiodarone 1 mg/minute via a peripheral IV infusion in the left hand. The unlicensed assistive personal (UAP) reports to the nurse that the client's heart rate is 90 beats/minute and blood pressure is 110/50 mm Hg. Which intervention should the nurse implement?

Tell the UAP to turn off the amiodarone.

Evaluate rhythm of client's heat rate.

Determine regularity of peripheral pulses.

Restart the IV infusion in another site.

Answer and Explanation

The Correct Answer is B

A.   The UAP should not make medication decisions; only a nurse or healthcare provider should do this after assessment.
B.   The nurse should evaluate the client’s heart rhythm to determine the effectiveness of the amiodarone and to assess for any arrhythmias or side effects of the medication.
C.   Checking the regularity of peripheral pulses is important but secondary to assessing the heart rhythm directly.
D.   Restarting the IV infusion might be necessary if there are issues with the IV site, but the primary concern is the client's cardiac status.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. A toileting schedule is unnecessary for an anuric client as they do not produce urine.
B. Anemia is a common complication of chronic kidney disease due to reduced erythropoietin production, so monitoring for signs of anemia is important.
C. High potassium foods should be avoided as impaired kidney function can lead to hyperkalemia.
D. While perineal skin care is important, it is not as critical as monitoring for anemia in this context.

A. Determine if the client has recently experienced a fall. B. Instruct the adult child to check the client's temperature. C. Ask if the client is experiencing any pain with urination. D. Encourage increased intake of high protein foods. E. Review the client's current food and medication allergies.

Correct Answer is ["A","B","C","E"]

Explanation

A. Falls can lead to head injuries or subdural hematomas, which can cause confusion in older adults. It is important to assess for recent trauma as a possible cause of the confusion.
B. An elevated temperature can indicate an infection, such as a urinary tract infection (UTI) or pneumonia, which are common causes of acute confusion in older adults.
C. Pain with urination is a symptom of a UTI, which can lead to confusion, especially in elderly patients with Parkinson's disease.
D. While maintaining adequate nutrition is important, increasing protein intake does not directly address the sudden onset of confusion.
E. New medications or allergic reactions can lead to confusion. A medication interaction or an allergic reaction to a new food could be a contributing factor.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning care for a client with chronic kidney disease who is a resident at a long-term nursing facility. The client is anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care?

Correct Answer is B

Explanation

The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. What action(s) should the nurse take? Select all that apply.

Correct Answer is ["A","B","C","E"]

Explanation

A client who is experiencing a severe level of anxiety reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

An older adult client presents to the emergency department with abdominal pain due to constipation. The nurse is providing a list of high-fiber foods to the client that the healthcare provider has recommended. Which action should the nurse implement when reviewing the list of foods?

The nurse is developing the plan of care for a client with pneumonia and includes the nursing problem of Ineffective airway clearance related to thick pulmonary secretions. Which intervention is most important for the nurse to include in the client's plan of care?

While completing an admission assessment for a client with unstable angina, which closed ended questions should the nurse ask about the client's chest pain?

The nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications?

The nurse is assessing the feet of a client with type 1 diabetes mellitus. Which finding requires immediate intervention by the nurse?