Nokea
An adult is brought in by ambulance after a motor vehicle accident. He is unconscious, on a backboard with his neck immobilized. He is bleeding profusely from a large gash on his right thigh. What is the first action the nurse should take?
- A. Stop the bleeding
- B. Take his vital signs
- C. Check his airway
- D. Find out what happened from eyewitnesses NEUROLOGIC DISORDERS
Correct Answer: C
Rationale: The correct answer is C: Check his airway. Ensuring a patent airway is the priority in trauma care to maintain oxygenation and ventilation. With the patient unconscious and bleeding profusely, airway obstruction or compromise is a critical concern. By checking the airway first, the nurse can quickly assess and address any immediate threats to the patient's breathing. Stopping the bleeding (choice A) can be addressed once the airway is secured. Taking vital signs (choice B) and finding out what happened from eyewitnesses (choice D) can be important but are secondary to ensuring the patient's airway is clear and unobstructed.
You may also like to solve these questions
The nurse is caring for a client in acute addisonian crisis. Which laboratory data would the nurse expect to find?
- A. Hyperkalemia
- B. Hypernatremia
- C. Reduced blood urea nitrogen (BUN)
- D. Hyperglycemia
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. In acute Addisonian crisis, the adrenal glands do not produce enough cortisol and aldosterone, leading to electrolyte imbalances. This results in increased potassium levels (hyperkalemia) due to lack of aldosterone to promote potassium excretion. Hypernatremia (choice B) is less likely as aldosterone deficiency leads to sodium loss. Reduced BUN (choice C) is unlikely as Addison's crisis does not directly affect urea levels. Hyperglycemia (choice D) is not typically seen in Addisonian crisis as cortisol deficiency usually results in hypoglycemia.
The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take?
- A. Ask the nursing assistive personnel if the wound looks better.
- B. Document the progress of wound healing as “better” in the chart.
- C. Measure the wound and observe for redness, swelling, or drainage.
- D. Leave the dressing off the wound for easier access and more frequent assessments.
Correct Answer: C
Rationale: The correct answer is C because measuring the wound and observing for redness, swelling, or drainage are essential steps in evaluating wound healing progress. Measuring the wound provides objective data on its size changes, while observing for signs of infection like redness, swelling, or drainage helps identify complications.
- Choice A is incorrect because the nursing assistive personnel may not have the necessary knowledge to assess wound healing accurately.
- Choice B is incorrect because documenting progress as "better" without objective data is subjective and does not provide a clear picture of the wound status.
- Choice D is incorrect because leaving the dressing off can expose the wound to contaminants and compromise healing, making it a potentially harmful action.
When monitoring for hypernatremia, the nurse should assess the client for:
- A. Dry skin
- B. Tachycardia
- C. Confusion
- D. Pale coloring
Correct Answer: C
Rationale: The correct answer is C: Confusion. Hypernatremia is an electrolyte imbalance characterized by high sodium levels in the blood. Confusion is a common symptom as high sodium levels can affect brain function. Dry skin (A) is more indicative of dehydration, tachycardia (B) is a symptom of various conditions, and pale coloring (D) is not specific to hypernatremia. Confusion is a key indicator that the nurse should assess for when monitoring for hypernatremia.
The nurse notes vigorous bubbling in the water-seal chamber of a chest-drainage system. Which of the following actions should the nurse take to correct the bubbling?
- A. Examine the entire system and tubing for air leaks.
- B. Lower the level of suction.
- C. Nothing; vigorous bubbling is expected
- D. Ask the patient to cough forcefully.
Correct Answer: A
Rationale: The correct answer is A. First, the nurse should assess the chest-drainage system and tubing for any air leaks. Air leaks can cause bubbling in the water-seal chamber, indicating a potential issue with the system's integrity. By examining the entire system, the nurse can identify and correct any leaks to ensure proper functioning of the chest-drainage system. Lowering the level of suction (choice B) may not address the underlying issue of air leaks. Doing nothing (choice C) is not appropriate as vigorous bubbling indicates a problem. Asking the patient to cough forcefully (choice D) is unrelated to addressing bubbling in the water-seal chamber.
A 52-year old female tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client’s lump is cancerous?
- A. Eversion of the right nipple and mobile
- B. Mobile mass that is soft and easily mass delineated
- C. Non-mobile mass with irregular edges
- D. Non palpable right axillary lymph nodes
Correct Answer: C
Rationale: The correct answer is C: Non-mobile mass with irregular edges. A non-mobile mass with irregular edges is more likely to be cancerous as it indicates potential infiltration into surrounding tissues. This finding raises suspicion for malignancy as cancerous lumps tend to have irregular shapes due to their invasive nature. In contrast, options A and B describe characteristics of benign masses, such as mobile, soft, and easily delineated. Option D indicates no palpable lymph nodes, which does not directly correlate with the characteristics of the breast lump. Therefore, option C is the most concerning and indicative of a potentially cancerous lesion based on the assessment findings provided.