Nokea
A client is admitted to the emergency room with multiple injuries. What is the proper sequence for managing the client?
- A. Assess for head injuries, control hemorrhage, establish an airway, prevent hypovolemic shock
- B. Control hemorrhage, prevent hypovolemic shock, establish an airway, assess for head injuries
- C. Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries
- D. Prevent hypovolemic shock, assess for head injuries, establish an airway, control hemorrhage
Correct Answer: C
Rationale: The ABCs of trauma care prioritize airway, breathing, and circulation. Establishing an airway comes first, followed by controlling hemorrhage and preventing shock, then assessing for head injuries.
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The nurse is performing discharge diet teaching to a client with a stage 1 decubitus ulcer on the coccyx. Which diet selection by this client would indicate that the client has a clear understanding of the proper diet for healing of a decubitus ulcer?
- A. Tossed salad, milk, and a slice of caramel cake
- B. Vegetable soup and crackers, and a glass of tea
- C. Baked chicken breast, broccoli, wheat roll, and an orange
- D. Hamburger, French fries, and corn on the cob
Correct Answer: C
Rationale: Healing a decubitus ulcer requires a diet high in protein, vitamins (especially C and A), and minerals like zinc. Baked chicken (protein), broccoli (vitamin A), wheat roll (carbohydrates), and orange (vitamin C) support tissue repair. The other options lack sufficient protein or include high-sugar/fat items that don't aid healing.
All of the following are risk factors for sudden infant death syndrome (SIDS) EXCEPT
- A. low birth weight.
- B. placing the child on his back to sleep.
- C. young maternal age.
- D. maternal smoking during pregnancy.
Correct Answer: B
Rationale: Placing an infant on their back to sleep reduces SIDS risk. Low birth weight, young maternal age, and maternal smoking are known risk factors.
A client with chronic obstructive pulmonary disease (COPD) is admitted to the respiratory unit. Which physician prescription should the nurse question?
- A. Oâ‚‚ at 5 L/min by nasal cannula
- B. Solu Medrol 125 mg IV push every 6 hours
- C. Ceftriaxone (Rocephin) 1gram IVPB daily
- D. Darvocet N 100 po prn pain
Correct Answer: A
Rationale: High-flow oxygen (5 L/min) can suppress the hypoxic drive in COPD clients, risking CO2 retention. Low-flow oxygen (1-2 L/min) is safer and should be questioned.
The patient is prescribed metronidazole (Flagyl) for adjunct treatment for a duodenal ulcer. When teaching about this medication, the nurse would include:
- A. This medication should be taken only until you begin to feel better.'
- B. This medication should be taken on an empty stomach to increase absorption.'
- C. While taking this medication, you do not have to be concerned about being in the sun.'
- D. While taking this medication, alcoholic beverages and products containing alcohol should be avoided.'
Correct Answer: D
Rationale: Metronidazole can cause a disulfiram-like reaction with alcohol, so avoidance is critical.
The nurse is monitoring a client's cardiac rhythm when an abnormal rhythm occurs. Which of the following cardiac rhythms does the ECG strip (see image) indicate?
- A. Ventricular fibrillation
- B. Ventricular tachycardia
- C. Atrial fibrillation
- D. Atrial flutter
Correct Answer: B
Rationale: Without the ECG strip, ventricular tachycardia (B) is a common abnormal rhythm requiring urgent intervention, characterized by wide QRS complexes. Other rhythms (A, C, D) have distinct patterns.