Nokea
A mentally retarded, nonverbal, ambulatory client is found sitting on the floor unable to get up. The LPN/LVN notes the client appears to be in great pain, and his right leg is out of alignment. What is the most important action for the nurse to take as the client is readied for ambulance transport?
- A. Give the client pain medication
- B. Immobilize the leg
- C. Gather any medical records that need to accompany the client
- D. Complete the incident report and other documentation
Correct Answer: B
Rationale: Immobilizing the leg prevents further injury in a suspected fracture, the priority action before transport.
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The nurse is teaching a client with a new diagnosis of migraine headaches about sumatriptan (Imitrex). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication at the first sign of a headache.
- B. I should avoid driving after taking this medication.
- C. I should report chest pain to my doctor.
- D. I should take this medication every morning to prevent headaches.
Correct Answer: D
Rationale: Taking sumatriptan daily to prevent migraines is incorrect, as it is used to abort acute attacks, not for prophylaxis. Options A, B, and C are correct: early use maximizes efficacy, sedation may impair driving, and chest pain may indicate vasoconstriction.
Treatment of sickle cell crises includes the application of:
- A. A heating pad to the joints
- B. An ice pack to the joints
- C. A CPM device to the lower leg
- D. A TENS unit to the back
Correct Answer: A
Rationale: Heat application to joints during sickle cell crises promotes vasodilation, improving blood flow and reducing pain from vaso-occlusion. Ice may worsen vasoconstriction, CPM is irrelevant, and TENS is not standard for sickle cell pain.
The nurse should anticipate the client with a gastric ulcer to have pain
- A. two to three hours after a meal.
- B. at night.
- C. relieved by ingestion of food.
- D. one-half to one hour after a meal.
Correct Answer: D
Rationale: pain related to a gastric ulcer occurs about one-half to one hour after a meal and rarely at night; is not helped by ingestion of food
A client has a history of oliguria, hypertension, and peripheral edema.
- A. Which nutrient should be restricted in a client with oliguria, hypertension, and peripheral edema (BUN 25, K+ 0 mEq/L)?
- B. Protein.
- C. Fats.
- D. Carbohydrates.
- E. Magnesium.
Correct Answer: A
Rationale: Oliguria, hypertension, and edema suggest renal impairment, where protein restriction reduces metabolic waste (e.g., urea nitrogen) that the kidneys cannot excrete. Fats and carbohydrates are encouraged, and magnesium restriction is not indicated.
A high school nurse observes a 14 year-old female rubbing her scalp excessively in the gym. The most appropriate course of action for the nurse to do is:
- A. Request a private evaluation of the female's scalp from her parents.
- B. Contact the female's parents about the observations.
- C. Observe the hairline and scalp for possible signs of lice.
- D. Contact the student's physician.
Correct Answer: C
Rationale: Observation of the student's hair is the next step.