Nokea
A nurse is the first on the scene of a motor vehicle accident. The victim has sucking sounds with respirations at a chest wound site and tracheal deviation toward the uninjured side. Until others arrive, the priority nursing action would be to
- A. loosely cover the wound, preferably with a sterile dressing.
- B. place a sandbag over the wound.
- C. monitor chest wound drainage.
- D. place a firm, airtight, sterile dressing over the wound.
Correct Answer: A
Rationale: implementation, in an open pneumothorax, air enters the pleural cavity through an open wound; placing a sterile dressing loosely over the wound allows air to escape but not reenter the pleural space
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A five-year-old is scheduled for a lumbar puncture (LP). Which of the following nursing actions would BEST prepare the child for the procedure?
- A. Explain the procedure in detail.
- B. Show a video of the procedure.
- C. Do a mock run-through of the procedure.
- D. Answer all questions simply and honestly.
Correct Answer: C
Rationale: excellent method to use with a child because it incorporates actually 'feeling' many aspects of the procedure as they are explained
The physician prescribes cimetidine (Tagamet) 300 mg PO qid for a 75-year-old man. The nurse instructs the client about the medication. Which of the following statements, if made by the client, would indicate that further teaching is needed?
- A. I'll take this pill with meals and before bed.
- B. I may experience mild diarrhea for a while.
- C. My stools may change color while I'm on this medication.
- D. I should call my doctor if I get an acne-like rash.
Correct Answer: C
Rationale: no change in stool color
The physician orders indomethacin (Indocin) 25 mg PO bid for a 34-year-old woman. It would be most important for the nurse to make which of the following statements?
- A. Take this medication with food.
- B. Take this medication one hour before meals.
- C. Take this medication one hour after meals.
- D. Take this medication with orange juice.
Correct Answer: A
Rationale: reduces GI upset
A client has come to the clinic for a hepatitis B vaccine and asks if he has to be re-vaccinated after his first injection. Which of the following responses by the nurse is BEST?
- A. A booster shot is required yearly.
- B. Additional injections are given at one and six months.
- C. Repeat doses are given at two and four months.
- D. Revaccination is not required.
Correct Answer: B
Rationale: hepatitis B vaccine is repeated at one and six months
While performing care for a 72-year-old woman, the nurse notices that the patient has a dry, parched mouth and tongue. The nurse should
- A. brush the patient's teeth with a hard-bristled toothbrush before meals and at bedtime.
- B. use glycerin swabs to perform mouth care every 4 hours.
- C. rinse the patient's mouth with room-temperature tap water before and after meals.
- D. use a water pick, then rinse with commercial mouthwash every 8 hours to freshen the mouth.
Correct Answer: C
Rationale: will hydrate the mucous membranes and keep mouth clean