Nokea
A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
- A. A client who is ambulatory and receiving oxygen
- B. A client who has a fracture and is in balance suspension traction
- C. A client who is bedridden and wears a hearing aid
- D. A client who uses a wheelchair and is confused
Correct Answer: A
Rationale: The correct answer is A: A client who is ambulatory and receiving oxygen should be evacuated first during a fire. This client has limited mobility due to the oxygen supply and is at high risk for respiratory compromise in a fire. Evacuating this client first ensures their safety and prevents potential harm.
Choice B: A client with a fracture in balance suspension traction requires stabilization but is not in immediate danger during a fire.
Choice C: A bedridden client wearing a hearing aid can be safely evacuated after the oxygen-dependent client.
Choice D: A confused client using a wheelchair may need assistance but is not at immediate risk like the oxygen-dependent client.
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Which of the following actions should the nurse take?
- A. Limit oral feedings to 30 min in length.
- B. Check the infant's oxygen saturation every 6 hr
- C. Place the infant in the prone position for naps
- D. Weigh the infant every other day.
Correct Answer: A
Rationale: Limiting feeding durations conserves energy for infants with heart failure.
A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?
- A. Position a pillow under the client's knees.
- B. Place a towel roll under the client's neck.
- C. Align a trochanter wedge between the client's legs
- D. Apply, an orthotic to the client's foot
Correct Answer: D
Rationale: The correct answer is D: Apply an orthotic to the client's foot. This intervention helps to maintain proper alignment of the foot, preventing contractures that can occur due to prolonged immobility. Placing a pillow under the client's knees (choice A) is beneficial for reducing pressure on the lower back but does not specifically address foot contractures. Similarly, placing a towel roll under the client's neck (choice B) is helpful for neck support but does not prevent foot contractures. Aligning a trochanter wedge between the client's legs (choice C) is aimed at hip alignment and not foot contractures. Therefore, the most appropriate intervention to prevent foot contractures in an immobile client is applying an orthotic to the client's foot.
Which of the following responses should the nurse make?
- A. It is always difficult caring for someone who is terminally ill.
- B. You should consider taking a sleeping pill before bed each night.
- C. I can give you information about respite care if you are interested.
- D. I am sure you're doing a great job taking care of your mother.
Correct Answer: C
Rationale: Respite care provides temporary relief for caregivers, which can improve their well-being.
After notifying the provider, the nurse should-----and then-----
- A. prepare the client for cardiac catheterization
- B. request a prescription for an increase in statin medication
- C. administer oxygen at 2 L/min via nasal cannula
- D. request a prescription for a beta-blocker
- E. check a STAT cardiac troponin
- F. administer sublingual nitroglycerin
Correct Answer: C,F
Rationale: Oxygen and nitroglycerin are initial interventions for chest pain relief.
Which of the following instructions should the nurse include?
- A. Monitor for weight loss
- B. Increase dietary calcium.
- C. Take on an empty stomach.
- D. Schedule dosage at bedtime
Correct Answer: B
Rationale: The correct answer is B: Increase dietary calcium. This instruction is important for a patient likely prescribed with a medication that can deplete calcium levels. Calcium is essential for bone health and overall well-being. Monitoring weight loss (A) is important but not directly related to the medication's side effects. Taking on an empty stomach (C) or at bedtime (D) may be specific to certain medications, but not universally applicable.