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A nurse is making a home visit when a fire starts in the client’s kitchen trash can. The client has a fire extinguisher. The nurse should take which actions to properly operate the fire extinguisher? Select all that apply.
- A. Aim the nozzle at the base of the fire
- B. Pull out the pin on the handle
- C. Shake the canister prior to use
- D. Squeeze the handle to spray
- E. Sweep the spray from side to side
Correct Answer: A,B,D,E
Rationale: Using the PASS technique (Pull, Aim, Squeeze, Sweep), the nurse should pull the pin, aim at the fire’s base, squeeze the handle, and sweep side to side to extinguish the fire. Shaking the canister is not required and may delay response.
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The nurse is preparing to administer 40 mg of oral furosemide. Prior to administering the medication, the nurse should evaluate which parameters? Select all that apply.
- A. Blood pressure
- B. Blood urea nitrogen
- C. Liver enzymes
- D. Potassium
- E. White blood cell count
Correct Answer: A,D
Rationale: Furosemide can cause hypotension and hypokalemia, so blood pressure and potassium levels must be evaluated. Blood urea nitrogen reflects kidney function but is not critical before administration, and liver enzymes and white blood cell count are unrelated.
A health care provider is screaming at the nurse in the hallway. 'Why didn't you get that surgery scheduled sooner?' What is the best response by the nurse?
- A. I am so sorry; I will get this fixed and schedule the surgery immediately
- B. I am uncomfortable with your tone, please excuse me while I locate my supervisor
- C. I delegated this task to the unlicensed assistive personnel: please follow up with them.
- D. I think you are overreacting, you should have specified the day and time
Correct Answer: B
Rationale: Responding calmly and redirecting to a supervisor de-escalates the situation professionally while addressing the inappropriate tone. Accusing the provider of overreacting is confrontational and unprofessional.
Which is the best way to position a client's neck for palpation of the thyroid?
- A. flexed toward the side being examined
- B. hyperextended directly backward
- C. flexed away from the side being examined
- D. flexed directly forward
Correct Answer: A
Rationale: Flexing the neck toward the side being examined relaxes the sternocleidomastoid muscle, facilitating thyroid palpation. Other positions make access more difficult. Health Promotion and Maintenance
The nurse is talking with a client with obsessive-compulsive disorder. When the client performs ritualistic behaviors, the nurse should recognize that the client
- A. is hearing voices
- B. is trying to control feelings of anger
- C. has an intense desire to control the environment
Correct Answer: C
Rationale: Ritualistic behaviors in OCD are driven by an intense need to control the environment or reduce anxiety through repetitive actions. They are not related to hearing voices or controlling anger, which are more associated with other disorders.
A concern regarding maternal and infant mortality and morbidity is that:
- A. a segment of the population is not receiving prenatal care.
- B. families appear unconcerned about quality health care.
- C. the personnel shortage in the maternity field will increase.
- D. maternal-child health workers are not adequately prepared.
Correct Answer: A
Rationale: Lack of prenatal care in some populations is a significant contributor to maternal and infant mortality and morbidity, as it prevents early intervention. The other concerns are less directly linked. Health Promotion and Maintenance