Nokea
A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse?
- A. Administer oxygen via non-rebreather mask
- B. Ensure the client has a patent airway
- C. Prepare to assist with suturing the artery
- D. Start two large-bore IVs with normal saline
Correct Answer: B
Rationale: Airway always takes priority, followed by breathing and circulation. Ensuring a patent airway is the first step before other interventions.
You may also like to solve these questions
A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Ambulate the client
- B. Apply a warm moist pack
- C. Massage the client's leg
- D. Provide an ice pack
Correct Answer: B
Rationale: Warm moist packs can help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the client's legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT.
A client is being discharged on warfarin (Coumadin) therapy. What discharge instructions is the nurse required to provide? (Select all that apply.)
- A. Dietary restrictions
- B. Driving restrictions
- C. Follow-up laboratory monitoring
- D. Drug-drug interactions
- E. Reason to take medication
Correct Answer: A,C,D,E
Rationale: Clients on warfarin need instructions on dietary restrictions, follow-up monitoring, drug interactions, and the reason for the medication, per The Joint Commission's Core Measures. Driving restrictions are not typically required.
A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding indicates a priority outcome for this client has been met?
- A. Pain rated as 2/10 after medication
- B. Distal pulse on affected extremity 2+/4
- C. Client remains on bedrest as directed
- D. Verifies understanding of procedure
Correct Answer: B
Rationale: Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4 indicates good perfusion, meeting a priority outcome. The other options are important but secondary to circulation.
Which factors does the nurse teach as contributing to aneurysm formation? (Select all that apply.)
- A. Atherosclerosis
- B. Down syndrome
- C. Frequent heartburn
- D. History of hypertension
- E. History of smoking
Correct Answer: A,D,E
Rationale: Atherosclerosis, hypertension, and smoking are major risk factors for aneurysm formation. Down syndrome and heartburn are not related.
The nurse is assessing a client on admission to the hospital. The client's leg appears with dependent rubor. What action by the nurse is best?
- A. Assess the client's ankle-brachial index
- B. Elevate the leg above the heart
- C. Obtain an ice pack to provide comfort
- D. Administer heparin sodium
Correct Answer: A
Rationale: Dependent rubor is a classic finding in peripheral arterial disease. The nurse should measure the ankle-brachial index to assess the severity. Elevating the leg or using ice could worsen circulation, and heparin is not indicated for this condition.