Nokea
All of the following clients are in need of an emergency assessment except:
- A. a bleeding client who has an injury from falling debris.
- B. an unresponsive client.
- C. a client with an old injury.
- D. a pregnant woman with imminent delivery.
Correct Answer: C
Rationale: The client with an old injury does not need an emergency assessment because this is not a life-threatening or new situation or condition.
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A nurse is returning phone calls in a pediatric clinic. Which of the following reports most requires the nurse's immediate attention and phone call?
- A. An untoward, adverse drug reaction associated with the quinolones is tendon rupture.
- B. Electrolyte imbalance has not been associated with the group, and antibiotic-associated colitis is most common in augmentin and penicillin groups.
- C. A 7 year-old boy has been having a low fever and headache for the past 3 days that has history of an anterior knee wound.
- D. A 7 year-old girl that had a cast on her right ankle is complaining of itching.
Correct Answer: B
Rationale: An untoward, adverse drug reaction associated with the quinolones is tendon rupture. Electrolyte imbalance has not been associated with the group, and antibiotic-associated colitis is most common in augmentin and penicillin groups.
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.
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.
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.
A health care agency has different receptacles for the various categories of institutional waste. Into which container should the nurse dispose of a suction canister used to collect bloody drainage from the client's NG tube?
- A. Injurious waste receptacle
- B. Hazardous waste receptacle
- C. Infectious waste receptacle
- D. Wastebasket in the client's bathroom
Correct Answer: C
Rationale: Blood and body fluids are classified as infectious waste, requiring disposal in the infectious waste receptacle.