Nokea
An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to:
- A. check the carotid pulse
- B. deliver 5 abdominal thrusts
- C. give 2 rescue breaths
- D. ensure an open airway
Correct Answer: D
Rationale: According to the ABCs of CPR, the first step in rescuing an unresponsive victim after checking responsiveness and calling for help is to open the victim's airway.
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Which nursing diagnosis is most appropriate for a client who has Cushing's syndrome?
- A. Risk for injury related to osteoporosis
- B. Pain related to cold intolerance
- C. Risk for deficient fluid volume related to excessive loss of sodium and water secondary to polyuria
- D. Risk for injury related to postural hypotension
Correct Answer: A
Rationale: Cushing's syndrome causes cortisol excess, leading to osteoporosis and increased fracture risk, making 'Risk for injury related to osteoporosis' the most appropriate diagnosis.
A nurse is providing care to a group of postpartum clients. Which client comment should prompt further investigation?
- A. I feel so exhausted that I started taking naps when the baby sleeps.
- B. I have trouble sleeping well at night because I worry that I won't hear the baby cry.
- C. My aunt has come over every day to care for the baby because the baby's cries bother me.
- D. My spouse thinks that I have been more emotional since I had the baby last week.
Correct Answer: C
Rationale: Being bothered by the baby's cries (C) may indicate postpartum depression, requiring investigation. Exhaustion (A), worry (B), and emotionality (D) are common postpartum experiences.
An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?
- A. A middle-aged client who says 'I took too many diet pills' and 'my heart feels like it is racing out of my chest.'
- B. A young adult who says 'I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?'
- C. An adolescent who was recently diagnosed with leukemia and started chemotherapy with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10
- D. An elderly client who reports having taken a 'large crack hit' 10 minutes prior to walking into the emergency room
Correct Answer: C
Rationale: Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opioid toxicity with the pinpoint pupils and has the least risk of complications occurring in the near future.
A 4-year-old admitted with Wilms tumor is scheduled for a right nephrectomy in the morning. Which nursing action is a priority pre-operatively?
- A. Assessment of the child's emotional maturity level
- B. Auscultating for adventitious breath sounds
- C. Monitoring blood pressure closely
- D. Reinforcing instructions not to palpate the abdomen
Correct Answer: D
Rationale: Avoiding abdominal palpation (D) prevents tumor rupture in Wilms tumor, a critical pre-operative priority. Emotional assessment (A), lung sounds (B), and BP monitoring (C) are important but secondary.
The family of a 90-year-old resident in a long-term care facility asks the nurse why the client only gets a shower three times a week. What information is most important for the nurse to include when answering the question?
- A. The staff members have limited time and must schedule all the residents.
- B. The client's skin is dry; too many showers will dry the skin further.
- C. The client has limited energy and must conserve it.
- D. The client is not very active and doesn't get very dirty.
Correct Answer: B
Rationale: Frequent showers can exacerbate dry skin in elderly clients, increasing irritation or breakdown risk. Staffing, energy, or activity levels are less relevant to skin health.