Nokea
A child on the playground is experiencing an anaphylactic reaction. The school nurse arrives with an EpiPen. The weather is cold and the child is wearing several layers of clothing. How should the nurse proceed with the EpiPen?
- A. Inject into the upper arm where the sleeve can be pulled up
- B. Inject into the most accessible vein
- C. Inject through the clothing into thigh and hold in place for 10 seconds
- D. Take the child inside, remove excess clothing, and inject into the thigh
Correct Answer: C
Rationale: Injecting through clothing into the thigh (C) ensures rapid administration during anaphylaxis. Arm injection (A) is incorrect, IV injection (B) is not for EpiPens, and delaying to remove clothing (D) is dangerous.
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The nurse is caring for a client with hyperosmolar hyperglycemic state (HHS). The nurse should recognize which characteristic is most consistent with HHS?
- A. Abdominal pain
- B. Altered level of consciousness
- C. History of type 1 diabetes
- D. Kussmaul respirations
Correct Answer: B
Rationale: Altered consciousness (B) is a hallmark of HHS due to severe hyperglycemia and dehydration. Abdominal pain (A) and Kussmaul respirations (D) are more typical of DKA, and HHS is associated with type 2 diabetes (C).
A postoperative client is having difficulty voiding. Palpation of the bladder indicates that the bladder is full. What should the nurse do initially?
- A. Ask the physician for a catheterization order
- B. Pour water over the client's perineum
- C. Encourage the client to take deep breaths
- D. Administer pain medication
Correct Answer: B
Rationale: Pouring water over the perineum stimulates the micturition reflex, aiding voiding non-invasively. Catheterization, breathing, or pain medication are secondary.
The nurse in a long-term care facility is caring for a client with major depressive disorder who is reporting difficulty sleeping. The client gets up during the night, paces the hallway, wrings the hands, and appears teary. Which of the following actions should the nurse take? Select all that apply.
- A. Arrange for the client to receive at least 20 minutes of natural sunlight each day
- B. Encourage the client to take naps during the day
- C. Instruct the client to engage in physical exercise just before bedtime
- D. Provide the client with a cup of warm milk in the evening
- E. Spend time with the client in a quiet environment just before bedtime
- F. Suggest that the client listen to soft music before going to bed
Correct Answer: A, D, E, F
Rationale: Natural sunlight exposure (A) helps regulate circadian rhythms and improve mood. Warm milk (D) contains tryptophan, which promotes sleep. A quiet environment (E) and soft music (F) reduce stimulation and promote relaxation. Naps (B) may disrupt nighttime sleep, and exercise before bedtime (C) can be stimulating.
A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular cancer. The client says to the nurse, 'I'm so worried that my future spouse is going to call off our engagement.' What is the best response by the nurse?
- A. Are you concerned about how the surgery will affect your sexuality?'
- B. If you are concerned about infertility, you could always bank your sperm.'
- C. The cancer is at an early stage. You are going to be fine.'
- D. What have you and your future spouse discussed about your condition?'
Correct Answer: D
Rationale: Asking about discussions with the spouse (D) encourages the client to share concerns and clarifies the situation. Options A, B, and C assume specific fears or provide reassurance without exploration.
The nurse is caring for an ambulatory client who has a new order for continuous cardiac monitoring via a portable unit. It would require follow-up if the nurse
- A. verifies that gel is present on each electrode and is not dried out
- B. cleanses and dries the skin before placing the electrodes on the client
- C. clips excessive hair off the client before applying the electrodes
- D. places one electrode each on the client's upper and lower extremities
Correct Answer: D
Rationale: Placing electrodes on extremities (D) is incorrect for cardiac monitoring, which requires chest placement. Verifying gel (A), cleansing skin (B), and clipping hair (C) are appropriate.