Nokea
Which action should the nurse take?
- A. Apply direct pressure to the wound with thick dressing material.
- B. Elevate the affected leg above heart level and apply light dressing.
- C. Apply a tourniquet immediately above the wound site.
- D. Apply ice packs to the wound to slow the bleeding.
Correct Answer: A
Rationale: The correct answer is A. Applying direct pressure to the wound with thick dressing material is the most appropriate action to control bleeding. It helps to compress the blood vessels, slowing down the bleeding. Elevating the leg (choice B) may not be enough to stop severe bleeding. Applying a tourniquet (choice C) should only be done as a last resort for life-threatening bleeding as it can lead to tissue damage. Applying ice packs (choice D) constricts blood vessels, potentially trapping harmful substances in the wound. It is crucial to address the immediate bleeding before considering other actions.
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Which action should the nurse take when working with the interpreter?
- A. Speak in a normal voice at a natural pace.
- B. Use medical jargon to ensure accuracy.
- C. Speak directly to the interpreter instead of the client.
- D. Ask the client to respond only with 'yes' or 'no' answers.
Correct Answer: A
Rationale: The correct answer is A: Speak in a normal voice at a natural pace. This is important because speaking clearly and at a natural pace allows the interpreter to accurately convey the message without missing any information. Using a normal voice also helps maintain a respectful and professional tone during communication.
Choice B is incorrect because using medical jargon may confuse the interpreter and lead to miscommunication. Choice C is incorrect as the nurse should always address the client directly to establish trust and rapport. Choice D is incorrect as it restricts the client's ability to express themselves fully.
Identify the sequence of steps the nurse should take?
- A. Close all nearby windows and doors
- B. Transport the client to another area of the nursing unit
- C. Use the unit's fire extinguisher to attempt to put out the fire
- D. Activate the facility's fire alarm system
Correct Answer: D
Rationale: The correct answer is D: Activate the facility's fire alarm system. This is the first step the nurse should take in case of a fire emergency to ensure the safety of all individuals in the facility. Activating the fire alarm alerts everyone in the building about the fire and prompts an immediate response from the fire department. Closing windows and doors (A) may help contain the fire but should not be the initial action. Transporting the client (B) could put them at risk and is not a priority. Using the fire extinguisher (C) should only be done if safe and appropriate, but activating the alarm is more crucial.
A nurse in emergency department is caring for a three-year old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation
- B. obtain a throat culture
- C. suction the child's oropharynx
- D. prepare a cool mist tent
Correct Answer: A
Rationale: The correct action is A: Prepare to assist with intubation. Epiglottitis is a medical emergency where the airway can become severely compromised due to swelling of the epiglottis. Intubation may be necessary to secure the airway and ensure adequate oxygenation. Prompt intervention is crucial to prevent respiratory distress and potential death. Obtaining a throat culture (B) may delay essential treatment. Suctioning the oropharynx (C) can stimulate the epiglottis and worsen the obstruction. A cool mist tent (D) does not address the immediate need for securing the airway.
For each assessment finding, click to specify if the finding is consistent with psychosis or mania.
- A. Hallucinations
- B. Lack of sleep
- C. Excessive spending habits
- D. Disorganized thought process
- E. Pressured speech
Correct Answer: A,B,C,D,E
Rationale: The correct answer is A, B, C, D, E. Hallucinations, lack of sleep, excessive spending habits, disorganized thought process, and pressured speech are all consistent with both psychosis and mania. Hallucinations are sensory perceptions without a real external stimulus, common in both conditions. Lack of sleep is a hallmark symptom of mania and can also exacerbate psychotic symptoms. Excessive spending habits are often seen in manic episodes due to impulsivity, and disorganized thought process and pressured speech are characteristic of both psychosis and mania, reflecting the underlying cognitive and communication disturbances. Other choices are not specific or commonly associated with psychosis or mania.
The nurse should recognize that which of the following findings is a complication of immobility
- A. Increased BP
- B. Urinary frequency
- C. Swollen area on calf
Correct Answer: C
Rationale: The correct answer is C: Swollen area on calf. Immobility can lead to blood pooling in the lower extremities, causing swelling, pain, and potentially leading to deep vein thrombosis (DVT). This is a serious complication that can result from prolonged periods of immobility. Increased blood pressure (choice A) is not typically a direct complication of immobility. Urinary frequency (choice B) is more commonly associated with conditions like urinary tract infections or overactive bladder, not immobility. Swollen area on the calf (choice C) is a hallmark sign of potential DVT in immobile patients.