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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When admitting a client with an abdominal wound, which precaution should be taken?
- A. Contact precautions
- B. Droplet precautions
- C. Airborne precautions
- D. Standard precautions
Correct Answer: A
Rationale: When admitting a client with an abdominal wound, contact precautions should be implemented. Contact precautions are used to prevent the spread of infections that are spread by direct or indirect contact. In the case of abdominal wounds, bacteria and pathogens can easily be transmitted through contact with the wound or wound drainage. Droplet precautions are used for infections transmitted through respiratory droplets, such as influenza. Airborne precautions are used for infections spread through the air, like tuberculosis. Standard precautions are used for all clients to prevent the spread of infections and should be followed in addition to specific precautions based on the type of infection.
The LPN is caring for a client who has been placed in restraints. What is the most important action for the nurse to take?
- A. Ensure that the client's circulation is checked every hour.
- B. Document the reason for the restraints every 4 hours.
- C. Provide range-of-motion exercises every 2 hours.
- D. Release the restraints every 2 hours for repositioning.
Correct Answer: D
Rationale: The most crucial action for the nurse to take when caring for a client in restraints is to release the restraints every 2 hours for repositioning. This practice helps prevent complications such as pressure ulcers and impaired circulation by ensuring adequate blood flow and preventing skin breakdown. Checking the client's circulation every hour (Choice A) is important, but releasing the restraints for repositioning takes precedence to prevent serious complications. While documenting the reason for restraints (Choice B) is essential for legal and documentation purposes, it is not as critical as providing necessary care to the client's physical well-being. Providing range-of-motion exercises (Choice C) is beneficial for maintaining mobility but may not address the immediate risks associated with prolonged restraint use.
A nurse in a surgical suite notes documentation on a client's medical record stating that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?
- A. Ensure sterilization of non-disposable items with ethylene oxide
- B. Wrap monitoring cords with stockinette and secure them with non-latex tape
- C. Cleanse latex ports on IV tubing with chlorhexidine before administering medication
- D. Wear hypoallergenic latex gloves that are powder-free
Correct Answer: B
Rationale: In this scenario, the nurse should take precautions to prevent latex exposure to the client due to his latex allergy. Wrapping monitoring cords with stockinette and securing them with non-latex tape helps to minimize the risk of latex contact with the client. Choice A is incorrect as sterilizing non-disposable items with ethylene oxide does not specifically address the avoidance of latex exposure. Choice C involves using latex ports on IV tubing, which can pose a risk of allergic reaction in a client with a latex allergy. Choice D suggests wearing latex gloves, even if hypoallergenic, which can still trigger a reaction in individuals with latex allergy. Therefore, the best option is to choose non-latex materials like stockinette and non-latex tape to prevent direct contact with latex.
The healthcare provider is caring for a 17-month-old with acetaminophen poisoning. Which lab reports should the healthcare provider review first?
- A. Prothrombin time (PT) and partial thromboplastin time (PTT)
- B. Red blood cell and white blood cell counts
- C. Blood urea nitrogen and creatinine levels
- D. Liver enzymes (AST and ALT)
Correct Answer: D
Rationale: In acetaminophen poisoning, liver damage is a significant concern due to the toxic effects of the drug on the liver. Liver enzymes such as AST (aspartate aminotransferase) and ALT (alanine aminotransferase) are essential markers to assess liver function and damage. Monitoring these enzymes early is crucial to detect hepatotoxicity and guide further management. Prothrombin time and partial thromboplastin time are coagulation studies and are not the priority in acetaminophen poisoning. Red and white blood cell counts are not specific to assess liver damage in this context. Blood urea nitrogen and creatinine levels are primarily used to evaluate kidney function, which is not the primary concern in acetaminophen poisoning.
When ambulating a frail, older adult client, the nurse should:
- A. Use the transfer belt if the client is unsteady
- B. Walk beside the client without support
- C. Encourage the client to use a walker
- D. Hold the client's arm for support
Correct Answer: A
Rationale: Using a transfer belt if the client is unsteady is essential to provide added safety and support during ambulation. This device helps the nurse assist the client in maintaining balance and prevents falls. Walking beside the client without support (choice B) may not offer enough assistance for a frail, older adult who is unsteady. Encouraging the client to use a walker (choice C) could be helpful in some cases, but if the client is unsteady during ambulation, additional support like a transfer belt is more appropriate. Holding the client's arm for support (choice D) may not provide enough stability and safety compared to using a transfer belt.