Nokea
A nurse is caring for a client who is in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
- A. Measure the duration of the seizure
- B. Restrain the client's arms and legs to prevent injury
- C. Lower the side rails of the bed when the seizure begins
- D. Insert an oral airway into the client's mouth
Correct Answer: A
Rationale: Measuring duration aids in assessing seizure severity and planning care.
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The client is 2 days postpartum and cannot afford to pay for baby formula.
A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the interprofessional team?
- A. Primary care provider
- B. Nutritionist
- C. Pediatric nurse practitioner
- D. Case manager
Correct Answer: D
Rationale: A case manager can connect the client to financial resources.
A nurse in a provider's office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department?
- A. Impetigo contagiosa
- B. Neisseria gonorrhoeae
- C. Human papillomavirus
- D. Sarcoptes scabiei
Correct Answer: B
Rationale: Neisseria gonorrhoeae (gonorrhea) is a reportable disease per public health regulations.
The child has pertussis.
A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?
- A. Facial erythema
- B. Peeling of the hands and feet
- C. Fever
- D. Beefy, red tongue
Correct Answer: C
Rationale: Fever is a common symptom of pertussis.
A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?
- A. Inject 15 units of air into the regular insulin vial.
- B. Withdraw 10 units of NPH insulin.
- C. Verify the dosage with another nurse.
- D. Place the cap over the needle.
Correct Answer: A
Rationale: Injecting air into the regular insulin vial next follows the correct sequence for mixing insulins.
A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. Droplet precautions require that I wear a gown and gloves when providing client care.
- B. Following a blood spill, I should use a bleach solution with a ratio of 1 to 20.
- C. Soiled dressings should be placed in a biohazard trash receptacle.
- D. For a client who has Clostridium difficile, I will cleanse my hands with an alcohol-based rub.
Correct Answer: C
Rationale: Soiled dressings in biohazard receptacles prevent infection spread, showing understanding.