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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The nurse is giving instructions to a group of women about breast self-examination. Which statement indicates that the client needs more instruction about the procedure?
- A. I will perform the exam every month after my period.'
- B. I should do the exam both standing and lying down.'
- C. Some ridges are normal in my breast.'
- D. I will do the breast self-exam every month until menopause.'
Correct Answer: D
Rationale: Breast self-exams should continue lifelong, not stop at menopause, as breast cancer risk persists. Other statements reflect correct technique.
As part of a routine health screening, the nurse notes the play of a 2-year-old child. Which of the following is an example of age-appropriate play at this age?
- A. builds towers with several blocks
- B. tries to color within the lines
- C. says 'Mine!' when playing with toys
- D. tries to jump rope
Correct Answer: C
Rationale: Saying 'Mine!' reflects the possessive, independent behavior typical of 2-year-olds. The other activities are either too advanced or not age-specific. Health Promotion and Maintenance
A client recovering from a head injury is receiving medication and nutritional feedings by nasogastric tube. The doctor has ordered medication to prevent seizure activity. The medication is supplied by the pharmacy in tablet form. Before administering the medication, the nurse should:
- A. Crush the medication and envelop it in a small amount of ice cream before giving.
- B. Help the client to sit upright while giving the tablet by mouth.
- C. Crush the tablet, mix in 100 ccs of tube feeding, and administer via NG tube.
- D. Ask the pharmacist if the medication is available in liquid form.
Correct Answer: D
Rationale: For NG tube administration, liquid medication is preferred to ensure proper delivery and absorption. Crushing tablets may alter efficacy, and oral administration is inappropriate.
The most common cause of injury from a house fire is:
- A. explosion.
- B. falls from second-story windows.
- C. thermal damage to skin and body surfaces.
- D. inhalation injury.
Correct Answer: D
Rationale: Inhalation injury, from smoke and toxic gases, is the most common cause of house fire injuries, often leading to respiratory compromise. Thermal damage is also significant but less frequent. Accident Prevention
The nurse is preparing to administer an acetaminophen suppository to a 4-year-old client. Which of the following actions should the nurse take? Select all that apply.
- A. Place the client in the side-lying position.
- B. Guide the suppository along the rectal wall.
- C. Use a gloved index finger to insert the suppository.
- D. Advance the suppository no further than the external sphincter.
- E. Hold the client's buttocks together firmly after inserting the suppository.
Correct Answer: A,C,E
Rationale: The side-lying position facilitates insertion, a gloved finger ensures hygiene, and holding buttocks prevents expulsion. Guiding along the rectal wall is unnecessary, and the suppository should be inserted beyond the external sphincter for absorption.