Nokea
The nurse responds to a train derailment.
After making an initial assessment, which of the following clients should the nurse see FIRST?
- A. A pregnant woman who states that her clothing is wet.
- B. A young man with blood pulsating from a cut on the right leg.
- C. A preschool child who is screaming and crying uncontrollably.
- D. An unconscious woman with the right leg shorter than the left leg.
Correct Answer: B
Rationale: Strategy: Think ABCs. (1) requires further assessment, could be amniotic fluid or it could be urine (2) correct-indicates arterial bleeding; apply direct pressure; high risk for shock (3) stable patient (4) possible hip fracture, no indication of respiratory difficulty stated
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The nurse is teaching a client with a new diagnosis of type 2 diabetes about insulin detemir (Levemir). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this insulin at bedtime.
- B. I should rotate injection sites.
- C. I should refrigerate unopened vials.
- D. I should take this insulin when my blood sugar is high.
Correct Answer: D
Rationale: Taking insulin detemir when blood sugar is high is incorrect, as it is a long-acting basal insulin for steady control, not for acute hyperglycemia. Options A, B, and C are correct: bedtime dosing is standard, rotation prevents lipodystrophy, and refrigeration preserves insulin.
A 53-year-old who has pernicious anemia is being seen in the physician's office. Because the client has pernicious anemia, which comment is of greatest concern to the nurse?
- A. I have been having trouble reading the newspaper.'
- B. I have pain up and down my legs.'
- C. My knees hurt when I climb stairs.'
- D. I am so tired of having a headache.'
Correct Answer: B
Rationale: Leg pain suggests worsening neuropathy, a serious complication of pernicious anemia, requiring urgent evaluation to prevent irreversible nerve damage.
A woman is admitted to the labor and delivery unit in a sickle cell crisis.
- A. Which nursing action is the highest priority for a woman in labor with a sickle cell crisis?
- B. Administer oxygen.
- C. Turn her to the right side.
- D. Provide adequate hydration.
- E. Start antibiotics.
Correct Answer: C
Rationale: Adequate hydration is the highest priority in sickle cell crisis to prevent further sickling of red blood cells and improve blood flow, reducing the risk of complications. Oxygen, repositioning, and antibiotics may be supportive but are not the primary intervention.
A client with acquired immunodeficiency syndrome (AIDS) is admitted with a tentative diagnosis of late AIDS dementia complex. The nursing assessment is most likely to reveal which of the following?
- A. Hyperactive deep tendon reflexes.
- B. Peripheral neuropathy affecting the hands.
- C. Disorientation to person, place, and time.
- D. Impaired concentration and memory loss.
Correct Answer: C
Rationale: approximately 65% of AIDS clients demonstrate a progressive dementia staged according to severity of debilitation; late stage is typified by cognitive confusion and disorientation
An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first?
- A. Lung sounds
- B. Urine output
- C. Level of alertness
- D. Appetite
Correct Answer: C
Rationale: Level of alertness. Assessing the level of consciousness (alert vs. lethargic vs. unresponsive) will help the provider determine the severity of the acute episode. If the client is alert, responses to questions about complaints can be followed-up quickly.