Nokea
A toddler who has swallowed several adult aspirin is admitted to the emergency room. When admitted, the child is breathing but is difficult to arouse. What is the immediate priority of care?
- A. Administration of syrup of ipecac
- B. Cardiopulmonary resuscitation
- C. Ventilatory support
- D. Gastric lavage
Correct Answer: D
Rationale: Gastric lavage is the priority to remove aspirin from the stomach, preventing further absorption, given the child is breathing but unresponsive.
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The nurse is preparing to administer the initial dose of an antibiotic in the emergency department. Which interventions should the nurse implement? Select all that apply.
- A. Assess for drug allergies.
- B. Collect needed specimens for culture.
- C. Check the client's armband.
- D. Ask the client his or her birthday.
- E. Draw peak and trough levels.
Correct Answer: A,B,C
Rationale: Allergy assessment prevents reactions, cultures guide therapy, and armband ensures identity. Birthday is redundant, and peak/trough levels are post-administration.
The provider has ordered transdermal nitroglycerin patches for a client. Which of these instructions should be included when teaching a client about how to use the patches?
- A. Remove the patch when swimming or bathing
- B. Apply the patch to any non-hairy area of the body
- C. Apply a second patch with chest pain
- D. Remove the patch if ankle edema occurs
Correct Answer: B
Rationale: Apply the patch to any non-hairy area of the body. The patch application sites should be rotated.
The client is complaining of incisional pain. Which intervention should the nurse implement first?
- A. Administer the pain medication STAT.
- B. Determine when the last pain medication was given.
- C. Assess the client's pulse and blood pressure.
- D. Teach the client distraction techniques to address pain.
Correct Answer: B
Rationale: Determining the last dose ensures safe timing and avoids overdose, the first step in pain management per nursing process.
When administering eye drops, the nurse should administer the drops into which location?
- A. The pupil
- B. The conjunctival sac
- C. The inner canthus
- D. The cornea
Correct Answer: B
Rationale: Eye drops are administered into the conjunctival sac to ensure proper distribution and minimize corneal irritation.
The client is diagnosed with tuberculosis and prescribed rifampin and isoniazid (INH), both antituberculosis medications. Which instruction is most important for the public health nurse to discuss with the client?
- A. The client will have to take the medications for nine (9) to 12 months.
- B. The client will have to stay in isolation as long as he or she is taking medications.
- C. Explain the client cannot eat any type of pork products while taking the medication.
- D. The urine may turn turquoise in color, but this is an expected occurrence and harmless.
Correct Answer: A
Rationale: TB treatment requires 9–12 months for cure, ensuring adherence is critical to prevent resistance, a public health priority. Isolation, pork, or urine color are incorrect or less urgent.