Nokea
A home health nurse finds the client lying unconscious in the doorway of her bathroom. The nurse checks for responsiveness by gently shaking the client and calling her name. When it is determined that the client is nonresponsive, the nurse should:
- A. Start cardiac compression
- B. Give two slow, deep breaths
- C. Open the airway using head-tilt, chin-lift maneuver
- D. Call for help
Correct Answer: C
Rationale: Opening the airway is the first step in managing an unresponsive client to ensure adequate ventilation.
You may also like to solve these questions
A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse's response is based on the knowledge that hemodialysis works by:
- A. Passing water through a dialyzing membrane
- B. Eliminating plasma proteins from the blood
- C. Lowering the pH by removing nonvolatile acids
- D. Filtering waste through a dialyzing membrane
Correct Answer: D
Rationale: Hemodialysis filters waste products and excess fluids through a dialyzing membrane, mimicking kidney function.
A client who has been taking Coumadin (warfarin) was stabbed in the upper arm. His prothrombin time is over twice the normal amount. The nurse anticipates an order for
- A. fresh frozen plasma
- B. whole blood
- C. platelets
- D. packed red blood cells
Correct Answer: A
Rationale: Elevated prothrombin time indicates excessive anticoagulation. Fresh frozen plasma provides clotting factors to reverse warfarin’s effect and control bleeding.
The nurse is caring for a client after an open reduction to the left ulna. The client's left arm is in a plaster cast with an Ace wrap for reinforcement. Which intervention by the nurse can offer nonpharmacological comfort to this client?
- A. elevate the left arm on a pillow and apply an ice pack over the approximate location of the surgical incision
- B. call the physician and obtain an order for acetaminophen (Tylenol) 650 mg PO PRN q6 hours as needed for pain
- C. advise the client that if he starts to itch under the cast, he can use a wire coat hanger or an ink pen to gently scratch up under the cast
- D. perform range-of-motion exercises twice a shift, including bending the fingers, opening and closing the hand, and lifting the arm up to shoulder level
Correct Answer: A
Rationale: Elevation and ice reduce swelling and pain nonpharmacologically. Scratching under the cast risks skin damage, and excessive movement may disrupt healing.
The physician has ordered a low-purine diet for a client with gout. Which protein source is high in purine?
- A. Dried beans
- B. Nuts
- C. Cheese
- D. Eggs
Correct Answer: A
Rationale: Dried beans are high in purines, which can increase uric acid levels and exacerbate gout symptoms.
The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?
- A. Macaroni and cheese
- B. Shrimp with rice
- C. Turkey breast
- D. Spaghetti with meat sauce
Correct Answer: C
Rationale: Turkey breast is lean and has the lowest saturated fat content compared to the other options, which contain higher-fat ingredients.