Nokea
A car accident involves four vehicles on a remote interstate. The nearest emergency department is 15 minutes away. Which victim should be transported by helicopter to the nearest hospital?
- A. 10-year-old with a simple fracture of the femur who is crying and cannot find his parents.
- B. Middle-aged woman with cold, clammy skin and a heart rate of 120 bpm who is unconscious.
- C. Middle-aged man with severe asthma and a heart rate of 120 bpm who is having difficulty breathing.
- D. 70-year-old man with a severe headache who is conscious.
Correct Answer: B
Rationale: The unconscious woman with signs of shock (cold, clammy skin, tachycardia) is in critical condition and requires immediate transport to stabilize her condition.
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The client has had a cataract removed. The nurse's discharge instructions should include which of the following?
- A. Keep the head aligned straight.
- B. Utilize bright lights in the home.
- C. Use an eye shield at night.
- D. Change the eye patch as needed.
Correct Answer: C
Rationale: Using an eye shield at night prevents rubbing the eye. The head should be turned to the side to scan the entire visual field to compensate for impaired peripheral vision. Eye medications may initially cause sensitivity to bright light. The surgeon changes the eye patch on the second postoperative day.
The nurse should instruct a young female adult with sickle cell anemia to do which of the following? Select all that apply.
- A. Drink plenty of fluids when outside in hot weather.
- B. Avoid travel to cities where the oxygen level is lower.
- C. Compare that since she is homozygous for HbS, she carries the sickle cell trait.
- D. Know that pregnancy with sickle cell disease increases the risk of a crisis.
- E. Avoid flying on commercial airlines.
Correct Answer: A,B,D
Rationale: Sickle cell anemia requires preventive measures to avoid crises. Drinking fluids in hot weather prevents dehydration, a trigger for sickling. Avoiding high-altitude cities reduces hypoxia risk, another trigger. Pregnancy increases the risk of crises due to increased metabolic demands. The statement about being homozygous for HbS is incorrect, as it indicates sickle cell disease, not the trait. Flying on commercial airlines is generally safe if the client is stable.
The son of a 78-year-old client with metastatic prostate cancer is asking the nurse about the purpose of hospice care. Which of the following statements by the nurse best describes hospice care?
- A. Hospice care uses a team approach to direct hospice activity.
- B. Clients and their families are the focus of care.
- C. The client's physician coordinates all the care.
- D. All hospice clients will die at home.
Correct Answer: B
Rationale: Hospice care focuses on the client and family, providing holistic support to enhance quality of life and comfort during the end-of-life phase.
The nurse monitors the client with pancreatitis for early signs of shock. Which of the following conditions is primarily responsible for making it difficult to manage shock in pancreatitis?
- A. Severity of intestinal hemorrhage.
- B. Loss of fluids into the retroperitoneal space.
- C. Infection from pancreatic necrosis.
- D. Decreased cardiac output.
Correct Answer: B
Rationale: Fluid sequestration into the retroperitoneal space (B) causes significant hypovolemia in pancreatitis, complicating shock management. Intestinal hemorrhage (A), infection (C), and cardiac output (D) are secondary or less common contributors.
Which is a priority assessment for the client in shock who is receiving an I.V. infusion of packed red blood cells and normal saline solution?
- A. Fluid balance.
- B. Anaphylactic reaction.
- C. Pain.
- D. Altered level of consciousness.
Correct Answer: B
Rationale: During a blood transfusion in a client in shock, the priority assessment is for an anaphylactic reaction, as transfusion reactions can be life-threatening and require immediate intervention. Fluid balance, pain, and consciousness are monitored but are secondary.