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An adult is brought in by ambulance after a motor vehicle accident. He is unconscious, on a backboard with his neck immobilized. He is bleeding profusely from a large gash on his right thigh. What is the first action the nurse should take?
- A. Stop the bleeding
- B. Take his vital signs
- C. Check his airway
- D. Find out what happened from eyewitnesses NEUROLOGIC DISORDERS
Correct Answer: C
Rationale: The correct answer is C: Check his airway. Ensuring a patent airway is the priority in trauma care to maintain oxygenation and ventilation. With the patient unconscious and bleeding profusely, airway obstruction or compromise is a critical concern. By checking the airway first, the nurse can quickly assess and address any immediate threats to the patient's breathing. Stopping the bleeding (choice A) can be addressed once the airway is secured. Taking vital signs (choice B) and finding out what happened from eyewitnesses (choice D) can be important but are secondary to ensuring the patient's airway is clear and unobstructed.
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Which of the following measures will not help correct the patient’s condition
- A. Offer large amount of oral fluid intake to replace fluid lost
- B. Give enteral or parenteral fluid
- C. Frequent oral care
- D. Give small volumes of fluid at frequent interval
Correct Answer: C
Rationale: Step-by-step rationale:
1. Providing oral care does not directly address fluid balance or hydration status.
2. Oral care focuses on maintaining oral hygiene and preventing infections.
3. Choices A, B, and D all involve fluid intake to address dehydration.
4. Offering large amounts of fluid, enteral or parenteral fluids, and small volumes at frequent intervals all aim to correct the patient's condition by replenishing lost fluids.
Summary:
Choice C is incorrect because oral care does not directly address the patient's dehydration. Choices A, B, and D are better options as they focus on fluid replacement to correct the patient's condition.
Which initial intervention is most appropriate for a patient who has a new onset of chest pain?
- A. Reassess the patient.
- B. Notify the health care provider.
- C. Administer a prn medication for pain.
- D. Call radiology for a portable chest x-ray.
Correct Answer: B
Rationale: The correct answer is B, notifying the health care provider. This is the most appropriate initial intervention because chest pain can be a symptom of a serious medical condition like a heart attack. The health care provider needs to be informed immediately to assess the situation and provide appropriate treatment. Reassessing the patient (A) may delay crucial medical intervention. Administering pain medication (C) without knowing the cause of chest pain can be dangerous. Calling radiology for a chest x-ray (D) is not the initial step in managing new onset chest pain.
A 52-year old female tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client’s lump is cancerous?
- A. Eversion of the right nipple and mobile
- B. Mobile mass that is soft and easily mass delineated
- C. Non-mobile mass with irregular edges
- D. Non palpable right axillary lymph nodes
Correct Answer: C
Rationale: The correct answer is C: Non-mobile mass with irregular edges. A non-mobile mass with irregular edges is more likely to be cancerous as it indicates potential infiltration into surrounding tissues. This finding raises suspicion for malignancy as cancerous lumps tend to have irregular shapes due to their invasive nature. In contrast, options A and B describe characteristics of benign masses, such as mobile, soft, and easily delineated. Option D indicates no palpable lymph nodes, which does not directly correlate with the characteristics of the breast lump. Therefore, option C is the most concerning and indicative of a potentially cancerous lesion based on the assessment findings provided.
At health fair, an oncology nurse answers questions about risk factors for various types of cancer. One person with a family history of colon cancer asks the nurse to identify risk factors for this type of cancer. The nurse should identify:
- A. Smoking
- B. Heavy alcohol consumption
- C. Obesity
- D. Saccharin consumption
Correct Answer: C
Rationale: The correct answer is C: Obesity. Obesity is a known risk factor for colon cancer as it can lead to chronic inflammation and changes in hormone levels, increasing the risk of developing cancerous cells in the colon. Smoking (choice A) is more strongly associated with lung cancer. Heavy alcohol consumption (choice B) is linked to increased risk of liver and esophageal cancer, not colon cancer. Saccharin consumption (choice D) has not been definitively linked to colon cancer. In summary, obesity is the most relevant risk factor for colon cancer among the choices provided.
A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless, temporary change?
- A. Purplish stools
- B. Redness of the upper part of the feet
- C. Bluish urine
- D. Coldness of the soles
Correct Answer: B
Rationale: The correct answer is B: Redness of the upper part of the feet. During lymphangiography, a contrast dye is injected into the lymphatic vessels. This may cause temporary redness in the upper part of the feet due to the dye spreading throughout the lymphatic system. Purplish stools (A), bluish urine (C), and coldness of the soles (D) are not expected side effects of lymphangiography and do not have a direct correlation with the procedure.