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A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?
- A. A client who has a small circular partial-thickness burn of the left calf.
- B. A client who has severe respiratory stridor and a deviated trachea.
- C. A client who has a splinted open fracture of the left medial malleolus.
- D. A client who has a massive head injury and is experiencing seizures.
Correct Answer: B
Rationale: The correct answer is B. The client with severe respiratory stridor and a deviated trachea should be assessed first as this indicates a compromised airway, which is a life-threatening emergency. Immediate intervention is crucial to prevent respiratory arrest. Clients with airway issues should always be the top priority in triage.
Other choices are incorrect because:
A: Small circular partial-thickness burn of the left calf is not immediately life-threatening and can be addressed after addressing more critical conditions.
C: Splinted open fracture of the left medial malleolus, while serious, does not present an immediate threat to the client's life compared to compromised airway.
D: Massive head injury and seizures are also serious, but in this scenario, the client with compromised airway takes precedence as airway issues can lead to rapid deterioration.
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A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have a natural childbirth. Which of the following responses should the nurse make?
- A. Maybe next time you can have a vaginal delivery.
- B. It sounds like you are feeling sad that things didn’t go as planned.
- C. At least you know you have a healthy baby.
- D. You can resume sensations sooner than if you had delivered vaginally.
Correct Answer: B
Rationale: The correct answer is B because it acknowledges the client's feelings of disappointment and validates her emotions. It demonstrates empathy and understanding, which can help build trust and rapport with the client. Choice A is incorrect as it may come off as dismissive or insensitive. Choice C focuses on the baby, not the client's feelings. Choice D is not relevant to the client's emotional concerns.
A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?
- A. Akathisia
- B. Tardive dyskinesia
- C. Dystonia
Correct Answer: B
Rationale: The correct answer is B: Tardive dyskinesia. Tardive dyskinesia is a common adverse effect of long-term antipsychotic medication use, such as chlorpromazine. It is characterized by involuntary movements of the tongue and face. This condition is often irreversible and can be distressing for the client. Akathisia (choice A) is a different extrapyramidal side effect characterized by restlessness and the urge to move constantly. Dystonia (choice C) is another extrapyramidal side effect that presents as sustained muscle contractions causing abnormal postures. In this case, the symptoms described in the question are more indicative of tardive dyskinesia due to the specific type of involuntary movements observed in the client.
A nurse is caring for a toddler who is 24 hours postoperative following a cleft palate repair. Which of the following actions should the nurse take?
- A. Apply bilateral wrist restraints.
- B. Administer opioids for pain.
- C. Implement a soft diet.
- D. Offer fluids through a straw.
Correct Answer: C
Rationale: Correct Answer: C. Implement a soft diet.
Rationale: A soft diet is appropriate post-cleft palate repair to minimize trauma to the surgical site and promote healing. It helps prevent injury and discomfort to the surgical area, allowing for adequate nutrition without causing harm.
Incorrect Choices:
A: Applying bilateral wrist restraints is unnecessary and could potentially harm the toddler, leading to increased agitation and discomfort.
B: Administering opioids for pain may not be necessary for a toddler post-cleft palate repair unless there are specific indications for severe pain.
D: Offering fluids through a straw can increase the risk of aspiration and compromise the surgical site's healing process. It is not recommended post-cleft palate repair.
A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply)
- A. Plan a plan of care for a client when postoperative from an appendectomy
- B. Provide discharge instructions to a confused client’s spouse
- C. Administer a tap-water enema to a client who is preoperative
- D. Clean vital signs from a client who is 6 hours postoperative
- E. Catheterize a client who has not voided in 8 hours
Correct Answer: C,D,E
Rationale: The correct tasks to delegate to the LPN are C, D, and E. For choice C, administering a tap-water enema to a preoperative client falls within the LPN's scope of practice as it involves a routine procedure that does not require advanced assessment or critical thinking skills. Choice D, cleaning vital signs from a client who is 6 hours postoperative, is a task that can be safely delegated to the LPN as it involves routine monitoring that does not require RN-level judgment. Choice E, catheterizing a client who has not voided in 8 hours, is a task that the LPN can perform as it is a straightforward procedure that the LPN would have been trained to do. Choices A and B involve more complex decision-making and education that are typically within the RN's scope of practice.
A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
- A. Dependent rubor
- B. Thick, deformed toenails
- C. Hair loss
- D. Edema
Correct Answer: D
Rationale: The correct answer is D: Edema. In chronic venous insufficiency, impaired blood flow leads to fluid accumulation in the affected limb, causing swelling or edema. This occurs due to increased venous pressure and decreased venous return. Dependent rubor (choice A) is seen in arterial insufficiency, not venous. Thick, deformed toenails (choice B) and hair loss (choice C) are not typically associated with chronic venous insufficiency. Edema is a hallmark sign due to venous stasis and capillary leakage.