Nokea
A nurse who is assigned to the emergency department needs to understand that gastric lavage is a priority in which situation?
- A. An infant who has been identified as suffering from botulism
- B. A toddler who has eaten a number of ibuprofen tablets
- C. A preschooler who has swallowed powdered plant food
- D. A school aged child who has taken a handful of vitamins
Correct Answer: A
Rationale: Botulinum toxin is a neurotoxin that causes muscular paralysis. Gastric lavage is a priority to remove the toxin from the stomach before it is absorbed.
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A nurse is implementing a community awareness campaign about accidental poisoning. Which of the following should she teach in the class?
- A. The child should be given milk.
- B. The child should be given syrup of Ipecac.
- C. The poison control center should be contacted.
- D. The child should be taken to the ER.
Correct Answer: C
Rationale: The poison control center should be contacted first to provide expert guidance on managing the poisoning.
Which statement by the nurse is appropriate when directing an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time?
- A. Have the client sit on the side of the bed for at least 2 minutes before helping him stand.
- B. If the client is dizzy on standing, ask him to take some deep breaths.
- C. Assist the client to the bathroom at least twice on this shift.
- D. After you assist him to the chair, let me know how he feels.
Correct Answer: A
Rationale: Give clear information to the UAP about what is expected for client safety. This instruction ensures the client is assessed for orthostatic hypotension before ambulating, reducing the risk of falls.
The nurse is discussing with the parents of the full-term newborn the infant's transportation in a vehicle. Which information should the nurse provide? Select all that apply.
- A. The infant should be restrained in a car seat located in the backseat facing the rear of the car.
- B. The infant should be restrained in a car seat located in the backseat facing the front of the car.
- C. An infant car seat may be designed only for infants; if so, obtain another one when the infant reaches the weight limit for that model.
- D. Some states and provinces in the United States and Canada have mandated the use of infant and child restraints.
- E. A car seat should have a certification label stating that it complies with federal motor vehicle safety standards.
Correct Answer: A,C,E
Rationale: A: Rear-facing car seats in the backseat are safest. C: Infant-only car seats have weight limits requiring replacement. E: Certification ensures safety compliance. B is incorrect as forward-facing is unsafe for infants.
A mother that has never breast-fed a child before is having trouble getting the baby to latch on to the breast. The baby has lost 3% of its birth weight within the first 2 days of life. The best statement is:
- A. The baby will eventually take to the breast.
- B. I can fix up a bottle if you want to try that.
- C. A small amount of weight loss in the first few days is normal.
- D. I can get the charge nurse to come and talk to you about breast-feeding.
Correct Answer: C
Rationale: 5-10% of birth weight loss following birth is normal for the first few days of life, and this response reassures the mother while allowing further discussion about breastfeeding challenges.
A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with
- A. a Dopamine drip IV with vital signs monitored every 5 minutes
- B. a myocardial infarction that is free from pain and dysrhythmias
- C. a tracheotomy of 24 hours in some respiratory distress
- D. a pacemaker inserted this morning with intermittent capture
Correct Answer: B
Rationale: This client is the most stable with minimal risk of complications or instability. The nurse can utilize basic nursing skills to care for this client, making it suitable for a nurse from another unit.