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An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next?
- A. Stay with client and observe for airway obstruction
- B. Collect pillows and pad the side rails of the bed
- C. Place an oral airway and use the body
- D. Announce a cardiac arrest, and assist with intubation
Correct Answer: A
Rationale: Stay with client and observe for airway obstruction. For the client's safety, remain at the bedside and observe respirations and level of consciousness. Prepare to clear the airway if obstructed. Do not place anything in the client's mouth. For safety, do not leave the client unattended. A cardiac arrest should only be announced if pulse or respirations are absent after the seizure.
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The nurse is planning care for a client with a cerebral vascular accident (CVA). Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?
- A. Place client in the wheelchair for four hours each day
- B. Pad the bony prominence
- C. Reposition every two hours
- D. Massage reddened bony prominence
Correct Answer: C
Rationale: Reposition every two hours. Clients who are at risk for skin breakdown develop fewer pressure ulcers when turned every two hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury is maintained.
The nurse is instructing the client who is to have surgery. According to Medicare's Surgical Care Improvement Project, what instruction is important for the client to receive prior to arrival at the hospital to prevent postoperative infection?
- A. Arrive in time to receive an antibiotic before surgery.
- B. Notify the nurse of any antibiotic and food allergies.
- C. Be sure to wash your hands before coming to the hospital.
- D. Do not shave hair from the surgical incision site.
Correct Answer: D
Rationale: D: Avoiding shaving prevents skin lacerations that increase infection risk. A, B: While important, they are managed in-hospital. C: Hand washing by the client is less critical.
The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to
- A. enhance absorption of the medication
- B. ensure that the entire dose of medication is given
- C. provide more even distribution of the drug
- D. prevent the drug from causing tissue irritation
Correct Answer: D
Rationale: prevent the drug from causing tissue irritation. Deep injection or Z-track is a special method of giving medications via the intramuscular route. Use of this technique prevents irritating or staining medications from being tracked through tissue. Use of Z-track does not affect dose, absorption, or distribution of the drug.
The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching?
- A. I use a sliding scale to adjust regular insulin to my sugar level.'
- B. Since my eyesight is so bad, I ask the nurse to fill several syringes.'
- C. I keep my regular insulin bottle in the refrigerator.'
- D. I always make sure to shake the NPH bottle hard to mix it well.'
Correct Answer: D
Rationale: I always make sure to shake the NPH bottle hard to mix it well.' The bottle should be rolled gently, not shaken.
A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first?
- A. Notify the health care provider
- B. Readjust the traction
- C. Administer the ordered prn medication
- D. Reassess the foot in fifteen minutes
Correct Answer: A
Rationale: Notify the health care provider. The findings are indicative of circulatory impairment. The health care provider must be notified immediately.