Nokea
A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency where the swelling of the epiglottis can rapidly obstruct the airway, leading to respiratory distress or failure. Intubation is crucial to secure the airway and ensure adequate oxygenation. Obtaining a throat culture (B) may delay necessary intervention. Suctioning the oropharynx (C) can trigger spasm and worsen the obstruction. Cool mist tent (D) does not address the immediate need for securing the airway.
You may also like to solve these questions
For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis.
- A. Hallucinations
- B. Lack of sleep
- C. Excessive spending habits
- D. Disorganized thought process
- E. Pressured speech
Correct Answer: A: Psychosis; B, C, D, E: Mania
Rationale: The correct answer is A: Psychosis; B, C, D, E: Mania. Hallucinations are typically associated with psychosis due to perceptual disturbances. Lack of sleep, excessive spending habits, disorganized thought process, and pressured speech are all characteristic features of mania, which is a key symptom of Bipolar Disorder. Mania involves elevated mood, increased energy levels, impulsivity, and risky behavior, such as excessive spending. Disorganized thought process and pressured speech are manifestations of the racing thoughts and flight of ideas seen in mania. In summary, while hallucinations are consistent with psychosis, the other findings (lack of sleep, excessive spending habits, disorganized thought process, pressured speech) are more indicative of mania due to the presence of manic symptoms.
A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following statements by the newly licensed nurse indicates an understanding of the procedure?
- A. I will hang a new bag of TPN and IV tubing every 24 hours.'
- B. I will obtain the client's weight every other day.'
- C. I will monitor the client's blood glucose level every 8 hours.'
- D. I will increase the rate of the TPN infusion to ensure the correct amount is given.'
Correct Answer: A
Rationale: Correct Answer: A - "I will hang a new bag of TPN and IV tubing every 24 hours."
Rationale: Changing the TPN bag and tubing every 24 hours is crucial to prevent contamination and infection. TPN is a high-risk solution that can support bacterial growth. Changing the bag and tubing decreases the risk of infection and ensures the client receives fresh and uncontaminated TPN.
Summary of Incorrect Choices:
B: Obtaining the client's weight every other day is important for adjusting the TPN formula but does not demonstrate an understanding of the procedure like changing the bag and tubing.
C: Monitoring the client's blood glucose level every 8 hours is important for assessing tolerance to TPN but does not directly relate to the procedural aspect of TPN administration.
D: Increasing the rate of TPN infusion to ensure the correct amount is given is not safe practice and can lead to complications. The rate should be prescribed by the healthcare provider and not arbitrarily increased.
A nurse is caring for a client whose child died from cancer. The client states, 'It's hard to go on without him.' Which of the following questions should the nurse ask the client first?
- A. What has helped you through difficult times in the past?'
- B. Has anyone in your family committed suicide?'
- C. Is there anyone you would like involved in your care?'
- D. Are you thinking about ending your life?'
Correct Answer: D
Rationale: The correct question to ask first is D: "Are you thinking about ending your life?" This is important to assess the client's risk of suicide, as the statement "It's hard to go on without him" can indicate suicidal ideation. It is crucial to address safety concerns immediately. Asking about coping strategies (A) can come later. Inquiring about family suicide history (B) may not be relevant at this stage. Involving others in care (C) is important but not as urgent as assessing suicidal thoughts.
A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively?
- A. Delegate tasks to the AP
- B. Determine goals of the day.
- C. Develop an hourly time frame for tasks
- D. Schedule daily activities
Correct Answer: B
Rationale: The correct answer is B: Determine goals of the day. This is the first step to managing time effectively as it helps prioritize tasks and establish a clear direction for care delivery. By setting goals, the nurse can focus on important tasks, delegate appropriately, and allocate time efficiently.
A: Delegating tasks to the AP can come after determining goals to ensure tasks are aligned with priorities.
C: Developing an hourly time frame for tasks can be done once goals are established to create a detailed schedule.
D: Scheduling daily activities is important but should be based on the goals set for the day.
In summary, determining goals of the day is the initial step in time management as it provides a framework for prioritizing tasks and organizing activities efficiently.
A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect?
- A. Calcium
- B. Folate
- C. Iron
- D. Zinc
Correct Answer: B
Rationale: The correct answer is B: Folate. Folate is essential for preventing neural tube defects in newborns. It helps in the formation of the neural tube during early pregnancy. Calcium (A) is important for bone health but not specifically for preventing neural tube defects. Iron (C) is crucial for preventing anemia but not directly related to neural tube defects. Zinc (D) is important for immune function and wound healing but not specifically for neural tube defects.