Nokea
A 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time?
- A. Continue CPR without using the automated external defibrillator (AED) until paramedics arrive
- B. Place one AED pad on the chest and the other on the back
- C. Place one AED pad on the upper right chest and the other on the lower left side
- D. Place one AED pad on the upper right chest and dispose of the other
Correct Answer: B
Rationale: For a 2-year-old, adult AED pads can be used by placing one on the chest and one on the back to accommodate smaller anatomy. Continuing CPR without AED delays defibrillation, and other options are incorrect pad placements.
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A school nurse is advising a class of unwed pregnant high school students. What is the most important action they can perform to deliver a healthy child?
- A. Maintain good nutrition
- B. Stay in school
- C. Keep in contact with the child's father
- D. Get adequate sleep
Correct Answer: A
Rationale: Maintain good nutrition. Adequate nutrition, especially protein, vitamins, and iron, is critical for healthy fetal development and reducing low-birth-weight risks.
A nurse is asked to float to the telemetry unit because the unit is short-staffed. The nurse is not familiar with this client population and is concerned about providing safe client care. What is the best action by the nurse?
- A. Accept the assignment and ask about what skills need to be performed
- B. Ask the nurse supervisor if a more experienced nurse can go instead
- C. Read the policy and procedure book for the unit before providing care
- D. Refuse to float to the unit because of concerns about client safety
Correct Answer: A
Rationale: Accepting the assignment and clarifying required skills ensures safe care with support, addressing concerns proactively. Refusing or deferring may disrupt staffing, and reading policies delays care.
The nurse is reinforcing teaching about foot care for a group of clients with diabetes mellitus. Which of the following information should the nurse include? Select all that apply.
- A. Dry the feet vigorously with a towel after bathing
- B. Use an over-the-counter kit to treat corns and calluses
- C. Use cotton or lamb’s wool to separate overlapping toes
- D. Wash the feet with lukewarm water
- E. Wear hard-sole shoes and do not go barefoot
Correct Answer: C,D,E
Rationale: Using cotton/wool for toes prevents pressure sores, lukewarm water avoids burns, and hard-sole shoes protect feet. Vigorous drying risks skin breakdown, and over-the-counter kits can cause injury in diabetic feet with poor sensation.
The nurse is caring for a client who had a seizure 10 minutes ago. The client is now confused and reports a headache. Which of the following phases of seizure activity should the nurse recognize the client is experiencing?
- A. Ictal phase
- B. Aural phase
- C. Postictal phase
- D. Prodromal phase
Correct Answer: C
Rationale: The postictal phase follows a seizure, characterized by confusion and headache as the brain recovers. Ictal is the seizure itself, aural involves pre-seizure sensations, and prodromal is vague premonitory symptoms.
A 79-year-old client asks the nurse if she needs any shots. She reports having had 'all the usual shots when I was younger.' Which immunization is most important for this person to receive?
- A. DPT
- B. MMR
- C. Pneumovax
- D. HiB
Correct Answer: C
Rationale: Pneumovax is critical for adults over 65 to prevent pneumococcal pneumonia, a significant risk in the elderly.