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A nurse is delegating tasks to the assistive personnel (AP). The nurse should direct the AP to complete which of the following tasks first?
- A. Assisting a client with a bed bath who has a history of falls
- B. Providing a snack to a diabetic client who is feeling lightheaded
- C. Feeding a client who has bilateral casts due to upper arm fractures
- D. Ambulating a postoperative client for the first time
Correct Answer: B
Rationale: The correct answer is B because providing a snack to a diabetic client who is feeling lightheaded addresses an immediate physiological need. Hypoglycemia can lead to serious complications and needs to be addressed promptly to prevent harm. Choices A, C, and D involve important tasks but do not address an urgent physiological need like hypoglycemia. Assisting a client with a bed bath, feeding a client with bilateral casts, or ambulating a postoperative client can be prioritized based on the client's condition and safety but do not take precedence over addressing a potential medical emergency like hypoglycemia.
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A nurse is providing education regarding biologic threats. When discussing anthrax, which of the following should be included as potential portals of entry? SELECT ALL THAT APPLY
- A. Central nervous system
- B. Integumentary system
- C. Respiratory system
- D. Renal system
- E. Gastrointestinal system
Correct Answer: B,C,E
Rationale: The correct answer includes the integumentary system (B), respiratory system (C), and gastrointestinal system (E) as potential portals of entry for anthrax. Anthrax can enter the body through broken skin (integumentary system), inhalation of spores (respiratory system), or ingestion of contaminated food/water (gastrointestinal system). The central nervous system (A) and renal system (D) are not typical routes of entry for anthrax. Central nervous system is not a common portal for anthrax entry, and the renal system is not a primary site for anthrax spore invasion.
A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?
- A. Insert a padded tongue blade into the client's mouth
- B. Restrain the client
- C. Move objects away from the client
- D. Place the client on his back
Correct Answer: C
Rationale: The correct answer is C: Move objects away from the client. This instruction is crucial to prevent injury during a seizure by creating a safe environment. Placing objects away from the client reduces the risk of them hitting or injuring themselves. It also allows for a clear space for the client's movements during the seizure.
Choice A is incorrect as inserting a padded tongue blade can cause injury and obstruct the client's airway. Choice B is incorrect as restraining the client can lead to further injury and is not recommended during a seizure. Choice D is incorrect as placing the client on their back can increase the risk of choking or aspiration if they vomit during the seizure.
A community health nurse is conducting an educational program on various environmental pollutants. The nurse should emphasize that clients who have which of the following disorders are especially vulnerable to ozone effects?
- A. Seasonal allergies
- B. Mitral valve disease
- C. Nasal polyps
- D. Asthma
Correct Answer: D
Rationale: The correct answer is D: Asthma. Clients with asthma are especially vulnerable to the effects of ozone due to their compromised respiratory system. Ozone can trigger asthma symptoms and exacerbate respiratory distress in individuals with asthma. Asthma is a chronic inflammatory condition of the airways, making it more susceptible to damage from environmental pollutants like ozone. Seasonal allergies (A), mitral valve disease (B), and nasal polyps (C) are not directly related to respiratory function and therefore not as vulnerable to ozone effects. In summary, asthma is the correct answer because of its direct impact on the respiratory system, making individuals with asthma more susceptible to the harmful effects of ozone.
A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?
- A. A negative-pressure isolation room
- B. A private room
- C. A semi-private room with a client who has pediculosis capitis
- D. A positive-pressure isolation room
Correct Answer: B
Rationale: The correct answer is B, a private room. Scabies is transmitted through direct skin-to-skin contact, so placing the client in a private room helps prevent spread to others. Choice A, a negative-pressure isolation room, is used for airborne infections. Choice C, a semi-private room with a client who has pediculosis capitis, is incorrect because scabies and head lice are different conditions with different modes of transmission. Choice D, a positive-pressure isolation room, is used to protect immunocompromised individuals from outside pathogens.
A nurse is teaching a client who has a new prescription for Sumatriptan (Imitrex) tablets to treat migraine headaches. Which of the following instructions should the nurse include?
- A. Chew tablet well before swallowing
- B. If you experience chest pain, call your physician immediately
- C. Take daily to prevent headaches
- D. Repeat dose in 1 hour for unrelieved headache
Correct Answer: B
Rationale: The correct answer is B: If you experience chest pain, call your physician immediately. This is crucial because Sumatriptan can sometimes cause chest pain or tightness as a side effect, which could indicate a serious issue like a heart problem. Instructing the client to contact their physician immediately ensures prompt medical attention if such symptoms occur, potentially preventing a serious complication. Choices A, C, and D are incorrect. A: Chewing Sumatriptan tablets is not recommended as it may alter the drug's absorption rate. C: Sumatriptan is not meant to be taken daily for headache prevention; it is used for acute migraine attacks. D: Repeating the dose in 1 hour is not advised as it can increase the risk of side effects and medication overuse headaches.