Nokea
An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which is normal should be placed on the tag? Select all that apply.
- A. Triage priority.
- B. Identifying information when possible (such as name, age, and address).
- C. Medications and treatments administered.
- D. Presence of jewelry.
- E. Next of kin.
Correct Answer: A,B,C
Rationale: Victim tags should include triage priority, identifying information, and treatments administered to ensure proper care and identification. Jewelry and next of kin are secondary considerations.
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Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the drug when chest pain occurs?
- A. Take one tablet every 2 to 5 minutes until the pain stops.
- B. Take one tablet and rest for 10 minutes. Call the physician if pain persists after 10 minutes.
- C. Take one tablet, then an additional tablet every 5 minutes for a total of three tablets. Call the physician if pain persists after three tablets.
- D. Take one tablet. If pain persists after 5 minutes, take two tablets. If pain still persists 5 minutes later, call the physician.
Correct Answer: C
Rationale: Standard protocol for sublingual nitroglycerin is one tablet every 5 minutes for up to three doses. If pain persists, the client should seek medical help.
The nurse should do which of the following to decrease a female client's anxiety about being placed in the lithotomy position for surgery?
- A. Explain in detail what will occur in the operating room.
- B. Determine what the client is concerned about.
- C. Pad the stirrups for comfort.
- D. Reassure the client that an all-female surgical team will be present.
Correct Answer: B
Rationale: Determining the client's specific concerns about the lithotomy position allows the nurse to address her anxiety directly, promoting trust and tailored reassurance.
A client with allergic rhinitis is instructed on the correct technique for using an intranasal inhaler. Which the patient is the client should demonstrate to the nurse that the client understands the instructions?
- A. I should limit the use of the inhaler to early morning and bedtime use.
- B. It is important to not shake the canister because that can damage the spray device.
- C. I should hold one nostril closed while I insert the spray into the other nostril.
- D. The inhaler tip is inserted into the nostril and pointed toward the inside nostril wall.
Correct Answer: C
Rationale: Holding one nostril closed while spraying into the other ensures proper delivery of the medication to the nasal mucosa. Limiting use to specific times is not typically required unless specified by the prescriber. Shaking the canister is often necessary for some inhalers to mix the medication. Pointing the inhaler toward the inner nostril wall is incorrect; it should be directed upward and slightly outward.
A client has just had an inguinal herniorrhaphy. Which of the following instructions would be most appropriate to include in his discharge plan?
- A. Turning, coughing, and deep breathing every 2 hours.
- B. Applying an ice bag to the scrotum.
- C. Raising the scrotum with a support.
- D. Remaining in a high Fowler's position while resting.
Correct Answer: B
Rationale: Applying an ice bag to the scrotum reduces swelling and discomfort post-inguinal herniorrhaphy. Turning and breathing are general postoperative care, scrotal support is not specified, and high Fowler's position is not necessary. CN: Physiological adaptation; CL: Synthesize
The nurse is reviewing the chart information for a client with increased ascites. The data include: temperature 37.2°C; heart rate 118; shallow respirations 26; blood pressure 128/76; and SpO2 89% on room air. Which action should receive priority by the nurse?
- A. Assess heart sounds.
- B. Obtain an order for blood cultures.
- C. Prepare for a paracentesis.
- D. Raise the head of the bed.
Correct Answer: D
Rationale: Low SpO2 (89%) and shallow respirations indicate respiratory compromise, likely from ascites pressing on the diaphragm. Raising the head of the bed (D) improves breathing. Heart sounds (A), blood cultures (B), and paracentesis (C) are secondary.