Nokea
A gastric lavage has been ordered for a client who is comatose and who ingested a full bottle of acetaminophen, a nonnarcotic analgesic. Which intervention should be included in the procedure? Select all that apply.
- A. Place the client on the left side with the head 15 degrees lower than the body.
- B. Insert a small-bore feeding tube into the naris.
- C. Have standby suction available.
- D. Withdraw stomach contents and then instill an irrigating solution.
- E. Send samples of the stomach contents to the laboratory for analysis.
Correct Answer: A,C,D,E
Rationale: Left-side positioning with head down prevents aspiration, suction clears secretions, withdrawing and irrigating removes poison, and lab analysis confirms ingestion. Small-bore tubes are inadequate for lavage.
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The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical unit. Which nursing task cannot be delegated to the UAP?
- A. Obtaining the intake and output on a client diagnosed with food poisoning.
- B. Performing a dressing change on the client with a chemical burn.
- C. Assisting a client who overdosed on morphine to the bedside commode.
- D. Help a client with carbon monoxide poisoning turn, cough, and deep breathe.
Correct Answer: B
Rationale: Dressing changes on chemical burns require assessment and sterile technique, a nursing task. Intake/output, ambulation, and turning are delegable to UAPs.
The nurse caring for a client with sepsis writes the client diagnosis of 'alteration in comfort R/T chills and fever.' Which intervention should be included in the plan of care?
- A. Ambulate the client in the hallway every shift.
- B. Monitor urinalysis, creatinine level, and BUN level.
- C. Apply sequential compression devices to the lower extremities.
- D. Administer an antipyretic medication every four (4) hours PRN.
Correct Answer: D
Rationale: Antipyretics (e.g., acetaminophen) address fever and chills, improving comfort. Ambulation, lab monitoring, and compression devices address other sepsis concerns, not comfort.
The father of a child brought to the emergency department is yelling at the staff and obviously intoxicated. Which approach should the nurse take with the father?
- A. Talk to the father in a calm and low voice.
- B. Tell the father to wait in the waiting room.
- C. Notify the child’s mother to come to the ED.
- D. Call the police department to come and arrest him.
Correct Answer: A
Rationale: A calm, low voice de-escalates the situation, promoting safety. Waiting room relocation, notifying the mother, or police involvement may escalate or delay resolution.
The nurse in the emergency department has admitted five (5) clients in the last two (2) hours with complaints of fever and gastrointestinal distress. Which question is most appropriate for the nurse to ask each client to determine if there is a bioterrorism threat?
- A. Do you work or live near any large power lines?
- B. Where were you immediately before you got sick?
- C. Can you write down everything you ate today?
- D. What other health problems do you have?
Correct Answer: B
Rationale: Asking about recent locations identifies potential common exposure points, critical for bioterrorism. Power lines, food intake, and comorbidities are less relevant.
The nurse working in an outpatient clinic is caring for a client who is experiencing epistaxis. Which intervention should the nurse implement first?
- A. Take the client’s blood pressure in both arms.
- B. Hold the nose with thumb and finger for 15 minutes.
- C. Have the client sit with the head tilted back and hold a tissue.
- D. Prepare to administer silver nitrate, a cauterizing agent, with a packing applicator.
Correct Answer: B
Rationale: Holding the nose for 15 minutes stops bleeding, the first intervention for epistaxis. BP, head tilting back (risks aspiration), and cauterization are secondary.