Nokea
A child is brought to the emergency department after being bitten on the arm by a neighborhood dog. Which is the priority question for the nurse to ask the parent of the child?
- A. How old is the dog?
- B. Does the dog have a history of biting?
- C. Are the child's immunizations up-to-date?
- D. Did the dog have all of its recommended shots?
Correct Answer: C
Rationale: When a bite occurs, the injury site of the bite should be cleansed carefully and the child should be given tetanus prophylaxis if immunizations are not up-to-date. The remaining options identify information that may have to be obtained, but are not the priority questions. Additionally the mother may not have the answers to these questions.
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The nurse is assessing a client's disposable closed chest drainage system at the beginning of the shift and notes continuous bubbling in the water-seal chamber. What should the nurse determine is the possible cause of the bubbling?
- A. The system is intact.
- B. A pneumothorax is resolving.
- C. The suction to the system is shut off.
- D. There is an air leak somewhere in the system.
Correct Answer: D
Rationale: Continuous bubbling in the water-seal chamber through both inspiration and expiration indicates that air is leaking into the system. A resolving pneumothorax would show intermittent bubbling in the water-seal chamber with respiration. Shutting the suction off to the system stops bubbling in the suction control chamber, but does not affect the water-seal chamber.
Prior to administering plasminogen activator (t-PA) to a client admitted with a stroke, the nurse should verify that the client: Select all that apply.
- A. Is older than 65 years.
- B. Has had symptoms of the stroke less than 3 years.
- C. Has a blood pressure within normal limits.
- D. Does not have active internal bleeding.
- E. Has not had an alcoholic beverage within the last 8 hours.
Correct Answer: C, D
Rationale: t-PA requires normal blood pressure and no active bleeding to minimize complications like hemorrhage.
A client who has Ménière's disease is experiencing an acute attack of vertigo. Which of the following interventions should the nurse include in the plan of care?
- A. Darken the client's room and provide a quiet environment.
- B. Provide a low-sodium, bland diet.
- C. Administer an opioid to relieve headache.
- D. Encourage fluid intake to prevent dehydration.
Correct Answer: A
Rationale: A dark, quiet environment reduces stimuli that can exacerbate vertigo in Ménière's disease.
Which oral contraceptive is considered safe for use while breast-feeding because it will not affect the breast milk or breast-feeding?
- A. Estrogen.
- B. Estrogen and progestin.
- C. Progestin.
- D. Testosterone.
Correct Answer: C
Rationale: Progestin-only contraceptives are safe during breast-feeding, as they do not affect milk production.
A client has cystitis. The nurse should further assess the client for:
- A. Flank pain.
- B. Oliguria.
- C. Nausea and vomiting.
- D. Foul-smelling urine.
Correct Answer: D
Rationale: Foul-smelling urine is a common symptom of cystitis due to bacterial infection. Flank pain and oliguria are more indicative of pyelonephritis.