Nokea
The ED nurse has triaged a client who was in a severe motor vehicle accident. He is unconscious with fractures to the left femur and left humerus and ulna. CT also reveals a large amount of internal hemorrhaging. No identification was found on the client at the scene. What is the correct action by the nurse?
- A. prepare the client for emergency surgery
- B. try to obtain informed consent from a family member
- C. wait until the client is conscious, and then obtain the consent
- D. ask police to run the tag number so the client can be identified
- E. inform the health care provider that consent cannot be obtained at this time
Correct Answer: A
Rationale: In life-threatening emergencies, implied consent allows preparation for surgery without delay, as internal hemorrhaging requires urgent intervention.
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The charge nurse is teaching unit nurses about droplet precautions. Which statement by one of the nurses indicates further teaching is needed by the charge nurse?
- A. Mumps is a viral infection that requires droplet precautions.
- B. Pharyngeal diphtheria is a viral infection that requires droplet precautions.
- C. Pertussis is a bacterial respiratory infection that requires droplet precautions.
- D. Mycoplasma pneumonia is a bacterial respiratory infection that requires droplet precautions.
Correct Answer: B
Rationale: Pharyngeal diphtheria is bacterial, not viral, requiring droplet precautions. The other statements are correct.
A newly graduated nurse is working in the pediatric unit. Which client assignment is most appropriate for this nurse?
- A. a 2-year-old with hemophilia A who has suddenly become less responsive
- B. a 15-year-old with sickle cell disease complaining of lower right quadrant abdominal pain
- C. a 6-year-old who just had a tonsillectomy 2 hours earlier and is frequently swallowing
- D. a 12-year-old with newly diagnosed type 2 diabetes whose parents need teaching on insulin
Correct Answer: D
Rationale: A 12-year-old with newly diagnosed type 2 diabetes requiring parental teaching is stable and appropriate for a new nurse, as it involves education rather than acute management. Options A, B, and C involve potentially unstable conditions requiring more experience.
The school nurse is assessing the readiness of a 16-year-old athlete who is diabetic. As the teenager becomes more physically active during the day, which management strategies should the nurse advise? Select all that apply.
- A. monitor blood glucose level before exercise
- B. always carry some form of high-protein, high-fat snack
- C. let the coach know the athlete is a diabetic
- D. inject insulin at least 30 minutes prior to athletic event
Correct Answer: A,C
Rationale: Monitoring blood glucose prevents hypoglycemia, and informing the coach ensures safety. High-protein, high-fat snacks are less effective than quick-acting carbohydrates, and insulin timing depends on the type used.
The RN is precepting a nursing student in the surgical ICU. The client is diabetic and asks the student nurse about insulin. Which response by the RN is best?
- A. ask the family to step out of the room to ensure client privacy
- B. tell the client that he should ask the health care provider when she rounds
- C. inform the client that the student nurse cannot answer questions regarding medication
- D. allow the nursing student to answer the client's question while the RN is present and can provide additional information if needed
Correct Answer: D
Rationale: Allowing the student to answer under supervision promotes learning while ensuring accurate information.