Reduction of Risk Potential

The cardiac monitor displays a rhythm that appears to be ventricular fibrillation. Which initial nursing action is appropriate?

• Initiate cardiopulmonary resuscitation

• Notify the health care provider

• Prepare to administer IV epinephrine

• Determine responsiveness of the client

A nurse is preparing a client diagnosed with a deep vein thrombosis (DVT) for a venous doppler evaluation. Which nursing intervention is necessary to prepare the client for this test?

• No special preparation is necessary for the client

• Have ready a sedative medication prior to the test

• Discontinue anticoagulant therapy just before to the test

• Keep the client NPO after midnight

The child diagnosed with thalassemia major has received several blood transfusions during the past three days. What lab value should be monitored closely during this therapy?

• Neutrophil percent

• Platelet count

• Hemoglobin

• Red blood cell indices

A nurse is caring for a client who had surgery to remove the gallbladder as well as a common bile duct exploration with the placement of a T-tube. The nurse observes copious amounts of drainage through the T-tube the day after surgery. Which action should the nurse take next?

• Lower the head of the bed

• Clamp the T-tube for two hours

• Continue to monitor the drainage

• Notify the registered nurse (RN) charge nurse immediately

A nurse is caring for a client who had surgery to remove the gallbladder as well as a common bile duct exploration with the placement of a T-tube. The nurse observes copious amounts of drainage through the T-tube the day after surgery. Which action should the nurse take next?

• Lower the head of the bed

• Clamp the T-tube for two hours

• Continue to monitor the drainage

• Notify the registered nurse (RN) charge nurse immediately

When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12 per minute. Which action should the nurse take first?

• Continue to monitor the respirations

• Try to vigorously stimulate normal breathing

• Measure the pulse oximetry

• Ask the registered nurse (RN) to assess the vital signs

The nurse is preparing the client for an intravenous pyelogram (IVP) test. Which intervention would the nurse perform?

• Instruct the client to maintain a regular diet 24 hours before the scheduled time

• Inform the client that only one x-ray of the abdomen is necessary

• Administer a laxative to the client the evening before the test

• Restrict the client's fluid intake four hours prior to the examination

A 78 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery six hours ago. He received 1000 mL of IV fluids. Which action would most likely help this client to void?

• Have him drink several glasses of water

• Wait two hours and have him try to void again

• Assist him to stand by the side of the bed to void

• Apply Crede’s method to the bladder from the bottom to the top

The client has been taking isoniazid (INH) and rifampin for several months to treat pulmonary tuberculosis. Which laboratory tests does the nurse anticipate will be ordered for this client.

• Cardiac enzymes

• Pancreatic enzymes

• Kidney function

• Liver enzymes

A pregnant woman in the third trimester is admitted with a report of painless vaginal bleeding over the last several hours. A nurse should prepare this client for what procedure?

• C-section

• Pelvic exam

• Nonstress test

• Abdominal ultrasound