Nokea
An adult who was struck by lightning is brought to the emergency department. Which action is of highest priority when the client is brought to the emergency room?
- A. Obtain an ECG
- B. Check blood gasses
- C. Dress wounds
- D. Check electrolytes
Correct Answer: A
Rationale: Lightning strikes can cause cardiac arrhythmias; obtaining an ECG is the highest priority to detect life-threatening rhythm disturbances. Gases, wounds, and electrolytes are secondary.
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The nurse discusses symptoms of the onset of labor with a 26-year-old primipara. Which of the following statements, if made by the client to the nurse, indicates a need for further teaching?
- A. I will note an increase in fetal movement.
- B. I may feel a gush of fluid run down my legs.
- C. I may see some blood in my vaginal discharge.
- D. I may experience a low backache.
Correct Answer: A
Rationale: Fetal movement decreases at labor onset due to limited space; expecting an increase indicates misunderstanding. Options B, C, and D are correct labor signs.
The nurse is teaching a community group about how to prevent Lyme disease. What should be included in the teaching? Select all that apply.
- A. Wear dark-colored clothing when outdoors.
- B. Tuck long pants inside socks.
- C. Wear long sleeves and long pants when outside.
- D. Remove standing water.
- E. Use insect repellant containing DEET.
- F. Do not eat venison.
Correct Answer: B,C,E
Rationale: Tucking pants into socks, wearing long clothing, and using DEET repel ticks, preventing Lyme disease. Light clothing aids tick visibility, standing water is irrelevant, and venison is safe.
A diabetic client asks the nurse why the provider ordered a glycosylated hemoglobin (HbA) measurement, since a blood glucose reading was just performed. You will explain to the client that the HbA test:
- A. Provides a more precise blood glucose value than self-monitoring
- B. Is performed to detect complications of diabetes
- C. Measures circulating levels of insulin
- D. Reflects an average blood sugar for several months
Correct Answer: D
Rationale: Glycosylated hemoglobin values reflect the average blood glucose (hemoglobin-bound) for the previous 2-3 months and can be used to monitor client adherence to the therapeutic regimen.
A client has been brought into the emergency room for treatment of a suspected drug overdose. The client appears to be highly agitated, fearful, and may be hallucinating.
The nurse should anticipate the client's need for
- A. immediate support from family and friends who accompanied her.
- B. a warm, friendly approach to reduce fears.
- C. a quiet, darkened room to decrease sensory stimulation.
- D. an immediate referral to a social service agency.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) inappropriate at this time because the client is not in contact with reality (2) may agitate the client further (3) correct-sensory stimulation would only increase agitation and could potentially lead to aggressive behavior and injury (4) not the priority at this time
The nurse is preparing a five-year-old child for surgery.
- A. What is the best action for the nurse when the informed consent for a five-year-old’s surgery is signed by the mother, and the parents are divorced with joint legal custody?
- B. Notify the physician.
- C. Inform surgery.
- D. Contact the father to obtain consent.
- E. Continue the child’s preoperative preparation.
Correct Answer: D
Rationale: In cases of joint legal custody, consent from either parent is sufficient for surgical procedures. Since the mother has signed the informed consent, no further action is needed, and the nurse should continue preoperative preparation. Notifying the physician, informing surgery, or contacting the father is unnecessary.