Nokea
A client is admitted to the emergency room with a gunshot wound to the right arm. After dressing the wound and administering the prescribed antibiotic, the nurse should:
- A. Ask the client if he has any medication allergies
- B. Check the client's immunization record
- C. Apply a splint to immobilize the arm
- D. Administer medication for pain
Correct Answer: C
Rationale: Immobilizing the arm with a splint prevents further tissue damage and promotes healing, which is a priority after initial wound care and antibiotic administration. Checking for allergies should have been done prior to administering antibiotics, and pain management, while important, is secondary to stabilization.
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Which of the following statements reflects Kohlberg's theory of the moral development of the preschool-age child?
- A. Obeying adults is seen as correct behavior.
- B. Showing respect for parents is seen as important.
- C. Pleasing others is viewed as good behavior.
- D. Behavior is determined by consequences.
Correct Answer: D
Rationale: Kohlberg's preconventional stage for preschoolers involves moral decisions based on consequences, such as avoiding punishment or gaining rewards.
The nurse is assessing a client for hypovolemia. Which laboratory result would help the nurse in confirming a volume deficit?
- A. Hematocrit 55%
- B. Potassium 5.0 mEq/L
- C. Urine specific gravity 1.016
- D. BUN 18 mg/dL
Correct Answer: A
Rationale: Hypovolemia causes hemoconcentration, increasing hematocrit (e.g., 55% is elevated). Potassium, urine specific gravity, and BUN within normal ranges don't confirm volume deficit.
A client is admitted to the medical-surgical unit with a report of severe hematemesis. The nurse should give priority to:
- A. Performing an assessment
- B. Obtaining a blood permit
- C. Initiating an IV with a large-bore needle
- D. Inserting an NG tube
Correct Answer: C
Rationale: Severe hematemesis indicates significant bleeding, requiring immediate IV access with a large-bore needle for fluid and blood resuscitation to stabilize the client.
Which of the following is NOT a component of evidence-based practice?
- A. outcomes of research studies
- B. culturally competent care
- C. patient values
- D. clinical expertise
Correct Answer: B
Rationale: Evidence-based practice integrates research outcomes, patient values, and clinical expertise. Culturally competent care is important but not a core component of EBP.
A client has ataxia following a cerebral vascular accident. The nurse should:
- A. Supervise the client's ambulation
- B. Measure the client's intake and output
- C. Request a consult for speech therapy
- D. Provide the client with a magic slate
Correct Answer: A
Rationale: Ataxia impairs coordination, increasing fall risk, so supervising ambulation is essential for safety.