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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The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?
- A. Assign an RN to provide total care of the client
- B. Assign a nursing assistant to help the client with self-care activities
- C. Delegate complete care to an unlicensed assistive personnel
- D. Supervise a nursing assistant for skin care
Correct Answer: D
Rationale: Supervise a nursing assistant for skin care. The nursing assistant can inspect the skin while giving hygiene care, but the nurse should supervise skin care since assessment and analysis are needed.
A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action?
- A. Discharge the client from home health care because of noncompliance
- B. Notify the provider of the client's failure to follow prescribed diet
- C. Discuss diet with the client to learn the reasons for not following the diet
- D. Make a referral to Meals-on-Wheels
Correct Answer: C
Rationale: Discuss diet with the client to learn the reasons for not following the diet. When new problems are identified, it is important for the nurse to collect accurate assessment data. Before reporting findings to the provider, it is best to have a complete understanding of the client's behavior and feelings as a basis for future teaching and intervention.
Which of these clients is the priority for the nurse to report to the public health department within the next 24 hours?
- A. An infant with a positive culture of stool for Shigella
- B. An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
- C. A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii
- D. A middle-aged nurse with a history of varicella zoster virus and with crops of vesicles on an erythematous base that appear on the skin
Correct Answer: B
Rationale: Tuberculosis is a reportable disease because persons who had contact with the client must be traced and often must be treated with chemoprophylaxis for a designated time.
The new NA is caring for the client who is at risk for a fall. Which statement by the nurse to the new NA is most important?
- A. "Remind the client to call for assistance before getting out of bed."
- B. "Clip the call light to the bedcovers so the client can find it easily."
- C. "Be sure the bed is in the lowest position when you leave the room."
- D. "Check that you have all four side rails up after you provide care."
Correct Answer: C
Rationale: Ensuring the bed is in the lowest position is critical to minimize injury from a fall, which poses a greater risk than other options. Four side rails (D) are considered a restraint and should be avoided.
When teaching a 10 year-old child about their impending heart surgery, which form of explanation meets the developmental needs of this age child?
- A. Provide a verbal explanation just prior to the surgery
- B. Provide the child with a booklet to read about the surgery
- C. Introduce the child to another child who had heart surgery 3 days ago
- D. Explain the surgery using a model of the heart
Correct Answer: D
Rationale: Explain the surgery using a model of the heart. According to Piaget, the school age child is in the concrete operations stage of cognitive development. Using a model to explain the surgery meets the child’s developmental needs for concrete and visual learning.