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An adult client has been admitted to the hospital with a 3-day history of uncontrolled vomiting and diarrhea. Which should the nurse assess for in this client? Select all that apply.
- A. Excitability
- B. Bradycardia
- C. Hypertension
- D. Poor skin turgor
- E. Flat peripheral veins
Correct Answer: D,E
Rationale: The client described in the question will most likely be dehydrated because of uncontrolled vomiting and diarrhea. The nurse assesses this client for weight loss, lethargy, or headache; sunken eyes; poor skin turgor (such as tenting); flat neck and peripheral veins; tachycardia; and low blood pressure.
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The nurse is planning care for a client who has sustained a spinal cord injury. The nurse should assess the client for:
- A. Anesthesia below the level of the injury.
- B. Tingling in the fingers.
- C. Pain below the site of the injury.
- D. Loss of position and vibratory sense.
Correct Answer: A,D
Rationale: Spinal cord injury often causes anesthesia (loss of sensation) and loss of position/vibratory sense below the injury level. Tingling or pain below the injury is less likely due to disrupted nerve pathways.
Which statement about automated external defibrillators is accurate?
- A. They are not as effective as regular defibrillators.
- B. They are replacing regular defibrillators in acute care settings.
- C. Only BLS certified people in the community should use them.
- D. They can be easily used by people with no healthcare experience.
Correct Answer: D
Rationale: AEDs are designed for use by laypersons with minimal training, making them accessible for public use in emergencies.
A schoolteacher asks the nurse whether all the children at school need treatment after exposure to a 7-year-old child with bacterial meningitis. The nurse responds that chemoprophylaxis should be given to:
- A. All children at the school.
- B. All household contacts and close contacts.
- C. The entire community.
- D. Household contacts only.
Correct Answer: B
Rationale: Chemoprophylaxis is recommended for household and close contacts of a child with bacterial meningitis to prevent secondary cases, not the entire school or community.
A 9-month-old child has been diagnosed with an ear infection. The father asks what else to do to help his child. The nurse can tell the father:
- A. Your child should also take an antihistamine.'
- B. The antibiotic is the only medicine necessary.'
- C. The ear in the ears helps the discomfort.'
- D. Over-the-counter eardrops often are helpful.'
Correct Answer: B
Rationale: Antibiotics are the primary treatment for bacterial ear infections; antihistamines and eardrops are not typically recommended unless prescribed.
A client with a new colostomy asks the nurse how to prevent skin irritation around the stoma. What is the best response by the nurse?
- A. Apply petroleum jelly around the stoma daily.'
- B. Clean the area with alcohol wipes before applying the pouch.'
- C. Ensure the skin barrier fits snugly and clean with mild soap.'
- D. Change the pouch only once a week.'
Correct Answer: C
Rationale: A snug-fitting skin barrier and cleaning with mild soap prevent skin irritation by protecting the peristomal skin and maintaining hygiene without causing trauma.