Nokea
A nurse is observing a local softball game when one of the players is hit in the nose with a ball. The player's nose is visibly deformed and bleeding. The best way for the nurse to control the bleeding is to:
- A. Tilt the head back and pinch the nostrils
- B. Apply a wrapped ice compress to the nose
- C. Pack the nose with soft, clean tissue
- D. Tilt the head forward and pinch the nostrils
Correct Answer: D
Rationale: Tilting the head forward and pinching the nostrils prevents blood from entering the airway and controls bleeding.
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The nurse is caring for a client with a history of schizophrenia who is experiencing auditory hallucinations. Which of the following interventions should the nurse implement?
- A. Argue with the client about the reality of the voices.
- B. Encourage the client to listen to music with earphones.
- C. Instruct the client to ignore the voices completely.
- D. Ask the client to describe the voices in detail.
Correct Answer: B
Rationale: listening to music can distract the client and reduce the intensity of auditory hallucinations
The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor:
- A. That cannot be assessed
- B. That is in situ
- C. With increasing lymph node involvement
- D. With distant metastasis
Correct Answer: B
Rationale: Tis indicates a tumor in situ, meaning it is noninvasive and confined to its original site, requiring specific care planning.
The nurse is preparing to administer a dose of enoxaparin (Lovenox) to a client with a pulmonary embolism. Which of the following actions by the nurse is correct?
- A. Administer the injection in the deltoid muscle.
- B. Massage the injection site after administration.
- C. Inject the medication into the abdomen, at least 2 inches from the umbilicus.
- D. Aspirate before injecting to check for blood return.
Correct Answer: C
Rationale: enoxaparin is administered subcutaneously in the abdomen, at least 2 inches from the umbilicus, without aspiration or massage
The client with varicella will most likely have an order for which category of medication?
- A. Antibiotics
- B. Antipyretics
- C. Antivirals
- D. Anticoagulants
Correct Answer: C
Rationale: Varicella (chickenpox) is a viral infection, and antivirals like acyclovir are commonly prescribed to reduce severity and duration.
The nurse has performed nutritional teaching on a client with gout who is placed on a low-purine diet. Which selection by the client would indicate that teaching has been ineffective?
- A. Cabbage
- B. Apple
- C. Peach cobbler
- D. Spinach
Correct Answer: D
Rationale: Spinach is high in purines, which can exacerbate gout. Cabbage, apples, and peach cobbler (if low in purine ingredients) are suitable for a low-purine diet.