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 is critical to prevent further damage to the injured area, reduce pain, and promote healing. Asking about allergies should have been done prior to administering antibiotics, checking immunization records is not a priority in this acute situation, and pain medication, while important, is secondary to stabilizing the injury.
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The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:
- A. Inspiration is longer than expiration
- B. Breath sounds are high pitched
- C. Breath sounds are slightly muffled
- D. Inspiration and expiration are equal
Correct Answer: D
Rationale: Inspiration is normally longer in vesicular areas. High-pitched sounds are normal in bronchial area. Muffled sounds are considered abnormal. Inspiration and expiration are equal normally in this area, and sounds are medium pitched.
The nurse is assessing a client with suspected dehydration. Which finding is most indicative?
- A. Increased urine output
- B. Dry mucous membranes
- C. Bradycardia
- D. Fever
Correct Answer: B
Rationale: Dry mucous membranes are a classic sign of dehydration due to reduced fluid volume. Decreased (not increased) urine output, tachycardia, and fever may occur but are less specific.
The nurse is preparing to check a client for Trousseau's sign. Which equipment should the nurse obtain?
- A. Tongue blade
- B. Blood pressure cuff
- C. Reflex hammer
- D. Stethoscope
Correct Answer: B
Rationale: Trousseau’s sign is elicited by inflating a blood pressure cuff on the arm to induce carpopedal spasm indicating hypocalcemia. The other equipment is not used for this assessment.
The nurse is teaching a client with a history of gout about dietary modifications. The nurse should tell the client to avoid:
- A. Green leafy vegetables
- B. Organ meats
- C. Whole grains
- D. Dairy products
Correct Answer: B
Rationale: Organ meats are high in purines, which increase uric acid levels, exacerbating gout, so they should be avoided.
A client is 6 weeks pregnant. During her first prenatal visit, she asks, 'How much alcohol is safe to drink during pregnancy?' The nurse's response is:
- A. Up to 1 oz daily
- B. Up to 2 oz daily
- C. Up to 4 oz weekly
- D. No alcohol
Correct Answer: D
Rationale: No amount of alcohol has been determined safe for pregnant women. Alcohol should be avoided owing to the risk of fetal alcohol syndrome. The recommended safe dosage of alcohol consumption during pregnancy is none.