Nokea
A 21-year-old male client is transported by ambulance to the emergency department after a serious automobile accident. He complains of severe pain in his right chest where he struck the steering wheel. Which is the primary client goal at this time?
- A. Reduce the client's anxiety.
- B. Maintain adequate oxygenation.
- C. Decrease chest pain.
- D. Maintain adequate circulating volume.
Correct Answer: B
Rationale: Maintaining adequate oxygenation is the primary goal in chest trauma to prevent hypoxia from pneumothorax or hemothorax. Anxiety, pain, and volume are secondary priorities.
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The nurse is caring for a client with acute angle-closure glaucoma of the right eye. It would be correct to place the client in which position?
- A. Trendelenburg
- B. Supine
- C. Right lateral decubitus with head end elevated
- D. Prone
Correct Answer: B
Rationale: Supine position is appropriate for angle-closure glaucoma to avoid increasing intraocular pressure. Trendelenburg and prone positions may worsen pressure, and right lateral decubitus is not specific to this condition.
The nurse is discharging a client who is prescribed antitubercular medications for pulmonary tuberculosis. The nurse is concerned about an adverse reaction to the medications if the client
- A. lives with a roommate and works as a flight attendant.
- B. has an implanted hormonal intrauterine device (IUD).
- C. smokes one pack of cigarettes per day.
- D. drinks three glasses of red wine each day.
Correct Answer: D
Rationale: Alcohol consumption, such as drinking three glasses of red wine daily, increases the risk of hepatotoxicity when taking antitubercular medications like isoniazid and rifampin, which are metabolized by the liver. Choice A is irrelevant to medication reactions, though it may pose a transmission risk. Choice B (IUD) and Choice C (smoking) do not directly interact with antitubercular medications to cause adverse reactions.
The nurse is preparing to administer a scheduled intramuscular injection to an apprehensive 4 year old child. Which therapeutic action should the nurse take?
- A. Draw a "magic circle" on the area before the injection.
- B. Have another nurse hold down the child.
- C. Apply EMLA cream to the area immediately before the injection.
- D. Administer the medication right after the child's nap.
Correct Answer: D
Rationale: Administering after a nap can reduce anxiety and discomfort in a child, as they are likely to be calmer.
Which dietary restriction is critical in acute renal failure?
- A. Low sodium.
- B. High protein.
- C. Low carbohydrate.
- D. High potassium.
Correct Answer: A
Rationale: Low sodium prevents fluid retention and hypertension in acute renal failure.
The nurse is assessing a client with dark skin for presence of a Stage I pressure ulcer. The nurse should:
- A. Use a fluorescent light source to assess the skin.
- B. L rescued the skin only when the Braden score is above 12.
- C. Look for skin color that is darker than the surrounding tissue.
- D. Avoid touching the skin during inspection.
Correct Answer: C
Rationale: In dark skin, Stage I pressure ulcers appear as darker areas compared to surrounding tissue, due to persistent redness or discoloration.