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A child is injured on the school playground and appears to have a fractured leg. What action should the school nurse take first?
- A. Call for emergency transport to the hospital
- B. Immobilize the limb and joints above and below the injury
- C. Assess the child and the extent of the injury
- D. Apply cold compresses to the injured area
Correct Answer: C
Rationale: The correct first action for the school nurse to take when a child is injured and appears to have a fractured leg is to assess the child and the extent of the injury. This initial assessment is crucial to determine the severity of the injury before proceeding with further interventions. Option A, calling for emergency transport, should only be done after assessing the extent of the injury. Option B, immobilizing the limb and joints, is important but should come after the initial assessment. Option D, applying cold compresses, is not recommended for suspected fractures as it can exacerbate swelling and pain.
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A nurse in a provider's office is collecting information from an older adult who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects?
- A. Liver damage
- B. Renal failure
- C. Gastric bleeding
- D. Heart attack
Correct Answer: A
Rationale: Correct Answer: Large doses of acetaminophen can cause liver damage, which is a known adverse effect of the medication. Acetaminophen is metabolized in the liver, and excessive amounts can overwhelm the liver's ability to process it, leading to hepatotoxicity. Renal failure (Choice B) is not typically associated with acetaminophen use. Gastric bleeding (Choice C) is more commonly linked to nonsteroidal anti-inflammatory drugs (NSAIDs) rather than acetaminophen. Heart attack (Choice D) is not a recognized adverse effect of acetaminophen, which primarily affects the liver when taken in large amounts.
During a physical assessment on a toddler, what should be the first action?
- A. Perform traumatic procedures
- B. Use minimal physical contact
- C. Proceed from head to toe
- D. Explain the exam in detail
Correct Answer: B
Rationale: The correct first action when performing a physical assessment on a toddler is to use minimal physical contact. This approach helps the toddler become comfortable and reduces anxiety during the assessment. Traumatic procedures (Choice A) should never be the first action as they can cause distress. Proceeding from head to toe (Choice C) is a common sequence in physical assessments but does not address the initial need to establish trust and comfort. Explaining the exam in detail (Choice D) is important but should come after establishing a rapport through minimal physical contact.
A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?
- A. Obtain client information
- B. Develop a plan of care
- C. Implement nursing interventions
- D. Evaluate the client's response to treatment
Correct Answer: A
Rationale: The correct answer is A: Obtain client information. The first step in the nursing process is assessment, which involves gathering data about the client's condition, needs, and preferences. This information forms the foundation for developing a comprehensive plan of care. Developing a plan of care (Choice B) comes after assessment to address the identified needs. Implementing nursing interventions (Choice C) follows the development of the plan of care. Evaluating the client's response to treatment (Choice D) occurs after implementing the interventions to determine the effectiveness of the care provided. Therefore, the initial and priority step is to obtain client information through assessment.
When moving a patient up in bed using a drawsheet with the help of another nurse, in which order will the nurses perform the steps, starting with the first one?
- A. Grasp the drawsheet firmly near the patient.
- B. Move the patient and drawsheet to the desired position.
- C. Position one nurse at each side of the bed.
- D. Place the drawsheet under the patient from shoulder to thigh.
Correct Answer: C
Rationale: When moving a patient up in bed with a drawsheet and the assistance of another nurse, it is important to have one nurse positioned at each side of the bed initially. This allows for proper coordination and support during the patient movement. Placing the drawsheet under the patient from shoulder to thigh, grasping the drawsheet firmly near the patient, and moving the patient and drawsheet to the desired position follow after the nurses are positioned on each side of the bed. The correct sequence ensures a safe and coordinated approach to repositioning the patient in bed.
An elderly client who requires frequent monitoring fell and fractured a hip. Which LPN/LVN is at greatest risk for a malpractice judgment?
- A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes.
- B. The nurse assigned to care for the client who was at lunch at the time of the fall.
- C. The nurse who transferred the client to the chair when the fall occurred.
- D. The charge nurse who completed rounds 30 minutes before the fall occurred.
Correct Answer: C
Rationale: The nurse who transferred the client to the chair when the fall occurred is directly involved in the event that led to the injury. Improper transfer techniques or lack of appropriate precautions during the transfer could have contributed to the fall and subsequent fracture of the hip. This direct involvement makes this nurse the one at greatest risk for a malpractice judgment. Choices A, B, and D are not as directly linked to the event that caused the injury. While poor nursing notes could be a factor, it is the immediate action of transferring the client that has a more direct impact on the client's fall and subsequent injury.