Nokea
An adult suffered a diving accident and is being brought in by an ambulance intubated and on backboard with a cervical collar. What is the first action the nurse would take on arrival in the hospital?
- A. Take the client vital signs
- B. Insert a large bore IV line
- C. Check the lungs for equal breath sounds bilaterally
- D. Perform a neurologic check using the Glasgow scale
Correct Answer: B
Rationale: The first action the nurse should take upon the arrival of the adult who suffered a diving accident and is intubated and on a backboard with a cervical collar is to insert a large bore IV line. This is a priority because the person may require urgent fluid resuscitation or medication administration, and having IV access is crucial for immediate intervention in trauma cases. After establishing IV access, other assessments such as vital signs, lung sounds, and neurological checks can follow.
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Under which of the ff situations should a nurse notify the physician when caring for a client with lymphangitis? Choose all that apply
- A. Affected area appears to enlarge
- B. Red streaks extend up the arm or leg
- C. Additional lymph nodes become
- D. Liver and spleen become enlarged
Correct Answer: A
Rationale: A nurse should notify the physician when caring for a client with lymphangitis under the following situations:
Which is a clinical manifestation of the systemic venous congestion that can occur with heart failure?
- A. Tachypnea
- B. Tachycardia
- C. Peripheral edema
- D. Pale, cool extremities
Correct Answer: C
Rationale: Peripheral edema is a common clinical manifestation of systemic venous congestion that can occur with heart failure. In heart failure, the heart is unable to pump effectively, leading to a backup of blood in the veins. This increased pressure in the veins causes fluid to leak out into the surrounding tissues, resulting in swelling or edema, most commonly in the lower extremities. Tachypnea (rapid breathing) and tachycardia (fast heart rate) are more associated with the compensatory mechanisms of the body to try to maintain cardiac output and oxygenation. Pale, cool extremities are more indicative of poor peripheral perfusion, which can occur with severe heart failure but are not the typical manifestations of systemic venous congestion.
Which of the following would indicate that the patient has a normal corneal light reflex?
- A. The eye focuses the image in the center of the pupil.
- B. The eyes converge to focus on the light.
- C. Constriction of both pupils occurs in response to bright light.
- D. Light is reflected at the same spot in both eyes.
Correct Answer: D
Rationale: A normal corneal light reflex, also known as the Hirschberg test, is assessed by shining a light into the patient's eyes and observing the reflection of the light on the corneas. In a normal response, the light should be reflected at the same spot in both eyes. If the light is off-center in one eye compared to the other, it could indicate a deviation in the alignment of the eyes, known as strabismus. Therefore, choice D, "Light is reflected at the same spot in both eyes," is the correct indicator of a normal corneal light reflex.
The age at which the infant can achieve early head control with bobbing motion when pulled to sit is
- A. 2 months
- B. 3 months
- C. 4 months
- D. 6 months
Correct Answer: A
Rationale: Head control typically begins developing around 2 months.
Place the following four nursing actions for the new laryngectomee in correct order of priority? i.Assist with ambulation ii.Set up a visit from a well-adjusted laryngectomee iii.Maintain a patent airway iv.Control postoperative pain
- A. 1, 2, 3, 4
- B. 3, 4, 1, 2
- C. 2, 3, 4, 1
- D. 4, 1, 2, 3
Correct Answer: C
Rationale: 1. Setting up a visit from a well-adjusted laryngectomee should be the first priority. This action will provide emotional support and guidance from someone who has gone through a similar experience, which can be extremely beneficial for the new laryngectomee in adjusting to their new situation and learning coping strategies.