Nokea
A client with a gastric ulcer is losing a significant amount of blood via the NG tube. The client's pulse is weak and thready, and she is hypotensive. A continuous irrigation of normal saline is ordered. How should the client be positioned?
- A. High Fowler's
- B. Semi-Fowler's
- C. Supine
- D. Left-side lying
Correct Answer: B
Rationale: Semi-Fowler's position helps prevent aspiration and facilitates gastric drainage in a hypotensive client with gastric bleeding.
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An elderly client with a fractured hip is placed in Buck's traction. The primary purpose for Buck's traction for this client is:
- A. To decrease muscle spasms
- B. To prevent the need for surgery
- C. To alleviate the pain associated with the fracture
- D. To prevent bleeding associated with hip fractures
Correct Answer: A
Rationale: Buck's traction immobilizes the hip to reduce muscle spasms, which can worsen pain and misalignment. It does not prevent surgery or bleeding and is not primarily for pain relief.
A client with acute glomerulonephritis requests a snack. Which snack is suitable given the client's dietary restrictions?
- A. Orange
- B. Banana
- C. Applesauce
- D. Raisins
Correct Answer: C
Rationale: Applesauce is a suitable snack for the client with acute glomerulonephritis. Answers A, B, and D are incorrect because oranges, bananas, and dried fruits such as raisins are high in potassium, which is restricted in the diet of the client with AGN.
A transfer truck carrying toxic chemicals derails, spilling the contents and emitting toxic fumes over several miles. As a result, many of the area residents complain of nausea, vomiting, and headache. According to the agent-host model, the host is:
- A. The train carrying the toxic chemicals
- B. Toxic fumes emitted by the derailed box cars
- C. Physical problems experienced by the residents
- D. The residents living in the area
Correct Answer: D
Rationale: In the agent-host model, the host is the affected individual (residents). The toxic fumes are the agent, and symptoms are the outcome.
A young adult client is scheduled for her first debridement of a second-degree burn of the left arm.
It is MOST important for the nurse to take which of the following actions?
- A. Assemble all necessary supplies and medications.
- B. Plan adequate time for the dressing change and provide emotional support.
- C. Prepare the client and family for the pain the client will experience during and after the procedure.
- D. Limit visitation prior to the procedure to reduce stress.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) appropriate, but is not a high priority (2) correct-planning for burn wound treatment should include organizing and planning to spend time not only on the mechanics of the procedure, but on providing the emotional support necessary for the client (3) appropriate, but is not a high priority (4) appropriate, but is not a high priority
A 15-year old is admitted following a motor vehicle accident. Examination reveals that the client has a closed head injury, a linear fracture of the temporal bone, a fracture of the mandible, and multiple abrasions. Upon admission, he is very drowsy. Which of the following orders would not be a part of the patient's care?
- A. Elevate the head 30°
- B. Apply Neosporin (neomycin) ointment to abrasions
- C. Polycillin (ampicillin) 500 mg IVPB q 6 hr
- D. Demerol (meperidine) 75 mg q 3-4 hr PRN pain
Correct Answer: D
Rationale: Demerol is contraindicated in head injuries due to its potential to mask neurological changes and increase intracranial pressure.