Nokea
A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first?
- A. Ask another nurse to help
- B. Delegate the task to unlicensed assistive personnel
- C. Premedicate the client for pain
- D. Verify the client's activity prescription
Correct Answer: D
Rationale: Verifying the activity prescription ensures the client is cleared for chair transfer, preventing injury. Assistance, delegation, or premedication are secondary until safety is confirmed.
You may also like to solve these questions
The afternoon following a thyroidectomy, the client experiences all of the following. Which one indicates to the nurse that the client is experiencing a serious complication?
- A. A sore throat
- B. Pain at the surgical site
- C. Temperature of 100.2°F
- D. Sudden hoarseness
Correct Answer: D
Rationale: Sudden hoarseness post-thyroidectomy may indicate vocal cord paralysis or hematoma compressing the airway, a serious complication requiring immediate attention. Sore throat, surgical pain, or mild fever are expected.
The nurse is acting as a preceptor for a student nurse in the labor and delivery unit. Which action by the student would require correction by the nurse?
- A. Removing gloves prior to removing isolation gown
- B. Using a nail brush to scrub underneath artificial nails
- C. Using alcohol-based hand sanitizer instead of washing hands when entering and exiting client room
- D. Washing hands and not wearing gloves when preparing medications in the med room
Correct Answer: B
Rationale: Artificial nails harbor bacteria, and scrubbing underneath is inadequate; they should be avoided in labor and delivery. Other actions align with infection control protocols.
A woman comes into the labor suite stating that her water has broken and she is in labor. Which symptoms point to the possible presence of placenta previa?
- A. Sudden knife-like pain in the lower abdomen accompanied by profuse vaginal bleeding
- B. Dark red vaginal discharge that started after she saw the physician this morning
- C. Bright red painless vaginal bleeding
- D. A tender rigid uterine wall and abdomen with no vaginal bleeding evident
Correct Answer: C
Rationale: Placenta previa typically presents with bright red, painless vaginal bleeding due to the placenta covering the cervix, distinguishing it from abruptio placentae or other conditions.
Which type of accidental poisoning would the nurse expect to occur in children under age 6?
- A. Oral ingestion
- B. Topical contact
- C. Inhalation
- D. Eye splashes
Correct Answer: A
Rationale: Oral ingestion. Young children are most likely to ingest toxic substances due to their exploratory behavior.
A 3 year-old child is treated in the emergency department after ingestion of 1 ounce of a liquid narcotic. What action should the nurse perform first?
- A. Provide the ordered humidified oxygen via mask
- B. Suction the mouth and the nose
- C. Check the mouth and radial pulse
- D. Start the ordered intravenous fluids
Correct Answer: C
Rationale: Check the mouth and radial pulse. Assessing airway, breathing, and circulation is the first step in treating toxic ingestion to stabilize the client.