Nokea
A client is admitted with severe injuries from an auto accident. The client's vital signs are BP 120/50, pulse rate 110, and respiratory rate of 28. The initial nursing intervention would be to
- A. begin intravenous therapy
- B. initiate continuous blood pressure monitoring
- C. administer oxygen therapy
- D. institute cardiac monitoring
Correct Answer: C
Rationale: Early findings of shock reveal hypoxia with rapid heart rate and rapid respirations, and oxygen is the most critical initial intervention. The other interventions are secondary to oxygen therapy.
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Which of the following interventions is most helpful in determining the need for oxygen therapy for a client with COPD?
- A. Asking the client whether he needs $\mathrm{O}_2$
- B. Assessing the client's level of fatigue
- C. Evaluating the hemoglobin level
- D. Using a pulse oximeter on the client's ear lobe
Correct Answer: D
Rationale: Pulse oximetry objectively measures oxygen saturation, guiding the need for oxygen therapy in COPD. Subjective reports and hemoglobin levels are less direct.
Which of the following findings suggests a complication in a client with surgical removal of a pituitary tumor?
- A. Polyuria
- B. Anuria
- C. Oliguria
- D. Dysuria
Correct Answer: A
Rationale: Polyuria may indicate diabetes insipidus, a common complication post-pituitary surgery due to disruption of antidiuretic hormone production.
A client comes to the emergency department reporting alkaline drain cleaner splashed into the eye. The conjunctiva of the affected eye is erythematous, and the client reports a burning sensation. What action is appropriate at this time?
- A. Administer PO analgesic medication
- B. Cover the affected eye with an eye patch
- C. Initiate continuous eye irrigation
- D. Perform a Snellen vision test
Correct Answer: C
Rationale: Ocular chemical burns require emergency care to prevent permanent vision loss. Alkali burns (eg, ammonia, cement, lye- containing drain cleanser) are particularly dangerous as they will quickly penetrate deep into the eye, causing severe, irreversible damage. For all types of ocular chemical burns, copious eye irrigation with sterile saline or water should begin immediately to flush the chemical irritant out of the eye
A new nurse on the unit notes that the nurse manager seems to be highly respected by the nursing staff. The new nurse is surprised when one of the nurses states: 'The manager makes all decisions and rarely asks for our input.' The best description of the nurse manager's management style is
- A. Participative or democratic
- B. Ultraliberal or communicative
- C. Autocratic or authoritarian
- D. Laissez faire or permissive
Correct Answer: C
Rationale: Autocratic or authoritarian. The manager’s decision-making without staff input indicates an autocratic leadership style.
Which of the following solutions is routinely used to flush an IV device before and after the administration of blood to a client?
- A. 0.9% sodium chloride
- B. 5% dextrose in water solution
- C. sterile water
- D. Heparin sodium
Correct Answer: A
Rationale: 0.9% sodium chloride (normal saline) is isotonic and compatible with blood, preventing cell lysis or clotting during IV flushing. The other solutions are inappropriate for this purpose. Pharmacological Therapies