Nokea
A nurse is at a local swimming pool, and a man collapses with a cardiac arrest after exiting the pool. The man is still wet when the nurse begins cardiopulmonary resuscitation (CPR), and another person brings the automated external defibrillator (AED). Which of the following should the nurse do next?
- A. Apply the AED pads and deliver a shock.
- B. Wipe the chest dry with an available cloth or towel.
- C. Continue CPR because a client who is wet cannot receive a shock.
- D. Wipe the chest with an alcohol hand wipe to speed the evaporation of the water.
Correct Answer: B
Rationale: Wiping the chest dry (B) ensures AED pads adhere properly and deliver an effective shock. Applying pads on a wet chest (A) risks ineffective defibrillation, continuing CPR (C) delays defibrillation, and alcohol wipes (D) are inappropriate.
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The oncology nurse is caring for a 24-year-old male client with testicular cancer. Cisplatin IV has been ordered. Which lab value would the nurse notify the health care provider about before administering this medication?
- A. iron 129 mcg/dL
- B. ammonia level 52 mcg/dL
- C. creatinine clearance 23 mL/minute
- D. brain natriuretic peptides (BNP) 36 pg/mL
Correct Answer: C
Rationale: Cisplatin is nephrotoxic; a creatinine clearance of 23 mL/min indicates impaired renal function, requiring provider notification before administration.
A mother asks the home health nurse for guidance on what foods are safe to give her child, who is on strict neutropenic precautions. The nurse looks at the mother's grocery list and advises her to avoid
- A. canned peaches.
- B. pasteurized whole milk.
- C. the fresh veggie tray.
- D. fresh bananas.
Correct Answer: C
Rationale: Neutropenic precautions require avoiding fresh, unprocessed foods (e.g., fresh veggies) due to bacterial risk. Canned, pasteurized, or peeled foods are safer.
An electrical fire occurs in a client's room shortly after the client returns from the recovery room after repair of a hip fracture with insertion of a prosthesis. What is the best method of removing the client from the room?
- A. Place the client in a wheelchair.
- B. Transfer the client to a gurney.
- C. Move the bed with the client on it.
- D. Do a two-person carry.
Correct Answer: C
Rationale: Moving the bed with the client on it (C) is the safest and fastest method to evacuate a post-surgical client with limited mobility during an emergency like a fire. Other methods (A, B, D) risk injury or delay.
A client with alcoholism has been instructed to increase his intake of thiamine. The nurse knows the client understands the instructions when he selects which food?
- A. Roast beef
- B. Broiled fish
- C. Baked chicken
- D. Sliced pork
Correct Answer: D
Rationale: Sliced pork is a rich source of thiamine (vitamin B1), which is critical for preventing Wernicke's encephalopathy in clients with alcoholism.
Which statement is true regarding the infant's susceptibility to pertussis?
- A. If the mother had pertussis, the infant will have passive immunity.
- B. Most infants and children are highly susceptible from birth.
- C. The newborn will be immune to pertussis for the first few months of life.
- D. Infants under 1 year of age seldom get pertussis.
Correct Answer: B
Rationale: Infants are highly susceptible to pertussis from birth, as maternal immunity is minimal, and severe cases are common in this age group.