Nokea
A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is
- 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: When applying the nursing process, assessment is the first step in providing care. The '5 Ps' of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis).
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The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention?
- A. Piercing the plastic of the ostomy pouch with a pin to vent the flatus
- B. Opening the bottom of the pouch, allowing the flatus to be expelled
- C. Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape
- D. Assisting the client to ambulate to reduce the flatus in the pouch
Correct Answer: B
Rationale: Opening the bottom of the pouch, allowing the flatus to be expelled, is the correct way to vent a 1-piece drainable ostomy pouch.
A client on suicide precautions is verbalizing other options besides suicide, appears to be responding to antidepressant medication, is sleeping and eating better, and has indicated a willingness to interact more with family members.
Based on this data, which of the following nursing actions is MOST appropriate?
- A. Recommend that the physician decrease the client's medication dosage.
- B. Recommend that the treatment team reevaluate the client's treatment plan.
- C. Give the client privileges to walk around the hospital by himself.
- D. Ask the family to begin planning for the client's discharge.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may reverse the client's progress (2) correct-data suggests that client is beginning to benefit from treatment; entire treatment team should share data and make a decision about the suicide precautions so that restrictions are changed gradually based on a full-data picture (3) may be the team's decision, but not until a thorough review of the case is completed (4) premature
The nurse is caring for a client receiving warfarin (Coumadin) 5 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I eat a salad with spinach every day.
- B. I take ibuprofen for my headaches.
- C. I drink a glass of red wine with dinner.
- D. I walk for 30 minutes every morning.
Correct Answer: B
Rationale: Ibuprofen, an NSAID, increases bleeding risk when taken with warfarin, a significant concern due to potential for hemorrhage. Options A, C, and D are less critical: spinach (vitamin K) may require dose adjustment, moderate wine is generally safe, and walking is beneficial.
The school nurse is teaching a group of preschool mothers about poison prevention in the home.
- A. Which statement by a mother indicates that further teaching is necessary?
- B. I should have a bottle of Ipecac for each of my children.'
- C. I should induce vomiting if my child swallows lighter fluid.'
- D. Giving my child water or milk may help dilute the poison.'
- E. Proper storage is the key to poison prevention in the home.'
Correct Answer: B
Rationale: Inducing vomiting after ingesting hydrocarbons like lighter fluid is contraindicated due to the risk of aspiration, which can cause severe lung damage. The other statements are correct: Ipecac is recommended for emergency use, diluting with water or milk can help, and proper storage is essential for prevention.
The nurse is caring for clients(width)clients in the pediatric clinic.
- A. Which cranial nerve should the nurse assess in an infant with a 'crooked' smile?
- B. III.
- C. V.
- D. VII.
- E. XI.
Correct Answer: C
Rationale: A crooked smile in an infant suggests facial muscle weakness, controlled by the facial nerve (VII), which governs facial expressions. Cranial nerves III (eye movement), V (sensation), and XI (neck/shoulder movement) are unrelated to smiling.