Nokea
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.
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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.
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 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.
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.