Nokea
A client is admitted with severe injuries from an auto accident. The client's vital signs are BP 120/50, pulse rate 110, and respiratory rate of 28. The initial nursing intervention would be to
- A. begin intravenous therapy
- B. initiate continuous blood pressure monitoring
- C. administer oxygen therapy
- D. institute cardiac monitoring
Correct Answer: C
Rationale: Early findings of shock reveal hypoxia with rapid heart rate and rapid respirations, and oxygen is the most critical initial intervention. The other interventions are secondary to oxygen therapy.
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How often must physical restraints be released?
- A. every 2 hours
- B. between 1 and 3 hours
- C. every 30 minutes
- D. at least every 4 hours
Correct Answer: A
Rationale: Physical restraints must be released every 2 hours to assess skin, circulation, and comfort, with checks every 30 minutes while restrained. Safety and Infection Control
The practical nurse is assisting the registered nurse in performing well-child examinations in a pediatric clinic. Which finding requires further evaluation?
- A. Chest rounded with the anteroposterior diameter equal to the lateral diameter in an infant
- B. Lateral curvature to the spine noted on examination of a 10-year-old girl
- C. Presence of an S3 heart sound in a 2-year-old
Correct Answer: B
Rationale: Lateral curvature of the spine in a 10-year-old suggests scoliosis, which requires further evaluation to prevent progression. A rounded chest in infants is normal due to developing lungs, and an S3 heart sound can be normal in young children.
The nurse is observing a staff member perform open suctioning for a client who has a tracheostomy tube. The nurse should intervene if the staff member is observed
- A. flushing the suction catheter with 0.9% sodium chloride after each suction pass
- B. placing the client in the semi-Fowler position prior to suctioning
- C. applying intermittent suction while inserting the suction catheter
Correct Answer: C
Rationale: Applying suction while inserting the catheter can cause tracheal mucosa damage and hypoxia. Flushing the catheter with saline maintains patency, and semi-Fowler position aids breathing and reduces aspiration risk during suctioning.
A chemical reaction between drugs prior to their administration or absorption is known as:
- A. a drug incompatibility.
- B. a side effect.
- C. an adverse event.
- D. an allergic response.
Correct Answer: A
Rationale: Drug incompatibility refers to chemical reactions between drugs before administration, like precipitation in IV lines. Side effects, adverse events, and allergic responses occur post-administration. Pharmacological Therapies
The nurse is assessing a 16-year-old mother for potential child abuse. Which factor is most important when assessing the potential for child abuse?
- A. Age of the mother
- B. Marital status
- C. Socioeconomic status
- D. Abuse as a child
Correct Answer: D
Rationale: A history of being abused as a child is the strongest predictor of potential child abuse, as it influences parenting behaviors.