Nokea
A 4-year-old is brought to the emergency department with sudden onset of a temperature of 103°F (39.5°C), sore throat, and refusal to drink. The child will not lie down and prefers to lean forward while sitting up. Which of the following should the nurse do next?
- A. Give 600 mg of acetaminophen (Tylenol) rectally, as ordered.
- B. Inspect the child's throat for redness and swelling.
- C. Have an appropriate-sized tracheostomy tube readily available.
- D. Obtain a specimen for a throat culture.
Correct Answer: C
Rationale: The symptoms suggest epiglottitis, a life-threatening condition requiring immediate airway management. Preparing a tracheostomy tube is the priority to ensure airway patency if obstruction occurs.
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The nurse finds a client lying on the floor next to the bed. After returning the client to bed, assessing for injury, and notifying the physician, the nurse fills out an incident report. Which of the following is the nurse's next action?
- A. Give the incident report to the nurse-manager.
- B. Place the incident report on the chart.
- C. Call the family to inform them.
- D. Omit mentioning the fall in the chart documentation.
Correct Answer: A
Rationale: The incident report should be given to the nurse-manager for review and follow-up, as it is an internal document for quality improvement, not part of the medical record.
You have collected, aggregated and analyzed data which reflects the frequency of your staff returning medical equipment to the appropriate department because the staff members thought it was too unsafe to use. After the experts in the medical equipment inspect and test the equipment they report back to you, as the nurse manager, whether or not the equipment was indeed unsafe. This data indicates that 83% of the returns that were made by your staff were deemed safe and operable. What should you do?
- A. Counsel the staff about their need to stop wasting the resources of this department.
- B. Check the equipment yourself to determine the accuracy of this equipment department.
- C. Ignore it because everyone can make an innocent mistake.
- D. Plan an educational activity about determining what equipment to send for repairs.
Correct Answer: D
Rationale: The high rate of unnecessary returns (83% safe equipment) indicates a knowledge deficit among staff about assessing equipment safety. Planning an educational activity addresses this issue effectively.
A client has soft wrist restraints to prevent her from pulling out her nasogastric tube. Which of the following nursing interventions should be implemented while the restraints are on the client?
- A. Instruct the client not to move while the restraints are in place
- B. Remove the restraints every 4 hours to provide skin care
- C. Secure the restraints to side rails of the bed
- D. Check on the client every 30 minutes while the restraints are on
Correct Answer: D
Rationale: Checking the client every 30 minutes ensures safety, circulation, and skin integrity while restraints are in use. Restraints should be removed every 2 hours for care, not 4, and securing to side rails is unsafe.
A client with a history of rheumatoid arthritis is prescribed prednisone. The nurse should monitor the client for which of the following adverse effects? Select all that apply.
- A. Hyperglycemia.
- B. Osteoporosis.
- C. Weight gain.
- D. Hypertension.
- E. Hypokalemia.
Correct Answer: A, B, C, D, E
Rationale: Prednisone can cause hyperglycemia, osteoporosis, weight gain, hypertension, and hypokalemia.
Which of the following would demonstrate the correct technique for applying an elastic bandage to a leg?
- A. Increase tension with each successive turn of the bandage.
- B. Start at the distal end of the extremity and move toward the trunk.
- C. Secure the bandage with clips over the area of the inner thigh.
- D. Overlap each layer twice when wrapping.
Correct Answer: B
Rationale: Starting at the distal end and moving toward the trunk promotes venous return and prevents constriction.