Nokea
The client has expired secondary to smallpox. Which information about funeral arrangements is most important for the nurse to provide to the client’s family?
- A. The client should be cremated.
- B. Suggest an open casket funeral.
- C. Bury the client within 24 hours.
- D. Notify the public health department.
Correct Answer: D
Rationale: Notifying the public health department is critical for smallpox, a highly contagious disease, to ensure containment. Cremation, open caskets, and rapid burial are secondary.
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The client has ingested a corrosive solution containing lye. Which intervention should the nurse implement?
- A. Administer syrup of ipecac to induce vomiting.
- B. Insert a nasogastric tube and connect to wall suction.
- C. Assess for airway compromise.
- D. Immediately administer water or milk.
Correct Answer: C
Rationale: Lye is corrosive, risking airway edema; assessing for compromise is critical. Ipecac is contraindicated, NG tubes are for non-corrosives, and water/milk may delay care.
Which intervention is most important for the nurse to implement when participating in a code?
- A. Elevate the arm after administering medication.
- B. Maintain sterile technique throughout the code.
- C. Treat the client’s signs/symptoms; do not treat the monitor.
- D. Provide accurate documentation of what happened during the code.
Correct Answer: C
Rationale: Treating the client’s clinical presentation (not just monitor readings) ensures appropriate care. Arm elevation, sterile technique, and documentation are secondary during active resuscitation.
The nurse writes a nursing diagnosis of 'risk for injury as a result of physical abuse by spouse' for a client. Which is an appropriate goal for this client?
- A. The client will learn not to trust anyone.
- B. The client will admit the abuse is happening and get help.
- C. The client will discuss the nurse’s suspicions with the spouse.
- D. The client will choose to stay with the spouse.
Correct Answer: B
Rationale: Admitting abuse and seeking help is a realistic goal to reduce injury risk. Distrust, confronting the spouse, or staying are unsafe or neutral.
The client in a code is now in ventricular bigeminy. The HCP orders a lidocaine drip at three (3) mg/min. The lidocaine comes prepackaged with two (2) grams of lidocaine in 500 mL of D5W. At which rate will the nurse set the infusion pump?
Correct Answer: 45
Rationale: Lidocaine concentration: 2 g = 2000 mg in 500 mL = 4 mg/mL. Dose: 3 mg/min. Rate = (3 mg/min) / (4 mg/mL) = 0.75 mL/min = 45 mL/hour (0.75 * 60). Pump set to 45 mL/hour.
The nurse is providing first aid to a victim of a poisonous snake bite. Which intervention should be the nurse’s first action?
- A. Apply a tourniquet to the affected limb.
- B. Cut an 'X' across the bite and suck out the venom.
- C. Administer a corticosteroid medication.
- D. Have the client lie still and remove constrictive items.
Correct Answer: D
Rationale: Immobilizing the limb and removing constrictive items (e.g., jewelry) prevents venom spread and swelling, the first action. Tourniquets, cutting, and steroids are outdated or secondary.