Nokea
A 16-year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse?
- A. Ask the teenager to wait until a parent or legal guardian can be contacted
- B. Withhold treatment until telephone consent can be obtained from the partner
- C. Refer the teenager to a community pediatric hospital emergency department
- D. Proceed with the triage process in the same manner as any adult client
Correct Answer: D
Rationale: The correct answer is to proceed with the triage process in the same manner as any adult client. In this scenario, since the teenager is legally married, they have the legal authority to consent to their own treatment. Choice A is incorrect because the teenager, being legally married, can provide their own consent. Choice B is incorrect as it unnecessarily delays treatment by waiting for telephone consent from the partner, which is not required in this case. Choice C is incorrect as the teenager can receive appropriate care in the current emergency department setting without the need for referral.
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At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart murmur due to aortic stenosis. To auscultate the aortic valve, where should the nurse place the stethoscope?
- A. Second intercostal space to the right of the sternum
- B. Fifth intercostal space to the left of the sternum
- C. Third intercostal space to the left of the sternum
- D. Fourth intercostal space at the midclavicular line
Correct Answer: A
Rationale: The correct location to auscultate the aortic valve is the second intercostal space to the right of the sternum. This area corresponds to the aortic valve area where aortic valve sounds are best heard. Choices B, C, and D are incorrect for auscultating the aortic valve. The fifth intercostal space to the left of the sternum is where the mitral valve is best heard, the third intercostal space to the left of the sternum is where the pulmonic valve is best heard, and the fourth intercostal space at the midclavicular line is where the tricuspid valve is best auscultated.
A client is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?
- A. "This test will indicate if you are at risk for developing blood clots."
- B. "This test will determine if your heart is performing properly."
- C. "This test will provide information about the function of your liver."
- D. "This test is used to check how your kidneys are working."
Correct Answer: C
Rationale: The correct answer is C: "This test will provide information about the function of your liver." Alanine aminotransferase (ALT) is an enzyme mainly found in the liver. An elevated ALT level may indicate liver damage or disease. Choices A, B, and D are incorrect because ALT is specifically related to liver function and not indicative of blood clot risk, heart performance, or kidney function.
The healthcare professional is preparing to administer potassium chloride intravenously to a client with hypokalemia. Which action is most important?
- A. Monitor the client's respiratory rate
- B. Check the client's urine output
- C. Administer the potassium chloride as a rapid IV push
- D. Dilute the potassium chloride in an appropriate IV solution
Correct Answer: D
Rationale: The correct answer is to dilute the potassium chloride in an appropriate IV solution. Potassium chloride should never be administered as a rapid IV push as it can lead to severe complications, including cardiac arrhythmias. Diluting the medication and administering it slowly helps reduce the risk of adverse effects. Monitoring the client's respiratory rate (Choice A) and checking urine output (Choice B) are important aspects of patient assessment but not the most crucial when administering potassium chloride. Administering potassium chloride as a rapid IV push (Choice C) is dangerous and can result in serious harm to the client.
A healthcare professional is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the healthcare professional use as a psychomotor approach to learning?
- A. Practice sessions
- B. Demonstrations
- C. Written instructions
- D. Group discussions
Correct Answer: A
Rationale: Practice sessions are an effective psychomotor approach to learning for adolescents with ostomies as they involve hands-on practice of ostomy care skills, which can help reinforce learning through active engagement. Demonstrations (choice B) can be helpful in providing visual guidance but may not offer the same level of active participation and practice as practice sessions. Written instructions (choice C) may be useful for reference but may not be as effective in developing psychomotor skills. Group discussions (choice D) focus more on verbal exchange and may not directly address the need for hands-on skill development required in managing ostomies. Therefore, practice sessions are the most suitable method for enhancing psychomotor learning in this scenario.
What intervention should be taken to minimize the risk for injury in a client with dementia?
- A. Use a bed exit alarm system.
- B. Place the client in restraints for safety.
- C. Ensure the client has frequent visitors to reduce isolation.
- D. Keep the client's room dark and quiet at night.
Correct Answer: A
Rationale: The correct intervention to minimize the risk for injury in a client with dementia is to use a bed exit alarm system. Bed exit alarms are effective tools to alert healthcare providers when a client attempts to get out of bed, helping prevent falls and injuries. Placing the client in restraints (Choice B) is not the preferred method as it can lead to physical and psychological harm, restrict mobility, and increase agitation. While social interaction is important for clients with dementia, ensuring frequent visitors (Choice C) is not directly related to preventing physical injuries. Keeping the client's room dark and quiet at night (Choice D) may be soothing for some clients but does not directly address the risk for injury associated with dementia.