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NGN/NCLEX Prep Questions/Rationales The nurse notes the presence of a P wave, QRS complex, flattened T waves, and occasional U waves on a client's cardiac monitor screen. Fill in the correct missing information by choosing from the lists of options in the drop-down menus.The nurse should suspect Your Answer: hypokalemia Correct Answer: hypokalemia because of the Your Answer: flattened T waves and occasional U waves Correct Answer: flattened T waves and occasional U waves
Rationale: Cardiac changes in hypokalemia include impaired repolarization, resulting in a flattening of the T wave and eventually the emergence of a U wave. Therefore, the nurse should suspect hypokalemia. The incidence of potentially lethal ventricular dysrhythmias is increased in hypokalemia. The nurse should immediately assess the client's vital signs and cardiac status for signs of hypokalemia. The nurse should also check the client's most recent serum potassium level and then contact the primary health care provider to report the findings and obtain prescriptions to treat the hypokalemic state.
The nurse is preparing a client for a chest x-ray and notes that the client is wearing a religious medal on a chain around the neck. What should the nurse do with regard to this personal item?Click to highlight the correct answer from the options provided.
The nurse should: (Select 1 option)
✓Ask the client if the chain and medal can be removed during the procedure.
Because: (Select 1 option)
✓The chain and medal may have cultural significance.
Rationale: Before certain diagnostic procedures, it is typical to have a client remove personal objects that are worn on the body because of client safety and the possibility of compromising test results. Therefore, the nurse should ask the client about the significance of such an item and its removal because it may have cultural or spiritual significance. If so, the nurse should ask
the client if the item can be either removed temporarily or placed on another part of the body during the procedure if appropriate.
While preparing a client for surgery scheduled in 1 hour, the client states to the nurse: "I have changed my mind. I don't want this surgery." Click to highlight the correct answer from the options provided.
The nurse should: (Select 1 option)
Cancel the surgery.Contact the surgeon.✓Discuss the client's concerns.Call the identified support person.
Because: (Select 1 option)
Client consent is required prior to any procedure.✓Further questions or concerns should be determined and addressed.Ethical considerations are important for a client undergoing surgery.The nursing scope of practice places limitations on how the nurse can respond.
Rationale: If the client indicates that he or she does not want a prescribed therapy, treatment, or procedure such as surgery, the nurse should further investigate the client's request. If the client indicates that he or she has changed his or her mind about surgery, the nurse should assess the client and explore with the client his or her concerns about not wanting the surgery.The nurse would then withhold further surgical preparation and contact the surgeon to report the client's request so that the surgeon can discuss the consequences of not having the surgery with the client. Further assessment and follow-up related to the client's request need to be done. It is the client's right to refuse treatment; however, further investigation is needed so the interventions can be tailored to specific needs.
The nurse notes that there has been an increase in the number of intravenous (IV) site infections that developed in the clients being cared for on the nursing unit. How should the
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