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As a general guide for emergency management of acute alcohol intoxication, it is important for the nurse initially to obtain data regarding which of the following?
- A. What and how much the client drinks, according to family and friends
- B. The blood alcohol level of the client
- C. The blood pressure level of the client
- D. The blood glucose level of the client
Correct Answer: B
Rationale: Blood alcohol levels are generally obtained to determine the level of intoxication. The amount of alcohol consumed determines how much medication the client needs for detoxification and treatment. Reports of alcohol consumption are notoriously inaccurate.
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The nurse is talking with a female client about collecting a clean-catch urine specimen. Which of the following information should the nurse include? Select all that apply.
- A. Avoid touching the inside of the specimen container.
- B. Position the specimen container before initiating your stream of urine.
- C. Cleanse your vulva from front to back with single-use antiseptic towelettes.
- D. Spread your labia using your nondominant hand before cleansing your perineum and urinating.
- E. Remove the lid from the specimen container and place it on the counter with the sterile side facing down.
Correct Answer: A,C,D
Rationale: Avoiding contamination, proper cleansing, and spreading the labia are critical for a clean-catch specimen. The lid should be placed sterile side up, and the container should be positioned midstream.
A woman who is pregnant for the first time asks the nurse when during pregnancy is the best time to take Lamaze classes. What should the nurse respond?
- A. During the first trimester
- B. During the second trimester
- C. During the third trimester
- D. Whatever fits into your schedule
Correct Answer: B
Rationale: The second trimester is ideal for Lamaze classes, as it allows time to learn techniques before labor while avoiding early pregnancy discomforts and late-term fatigue.
The nurse is collecting data from a client during a routine physical examination. Which of the following findings would be most important to report to the health care provider?
- A. BMI of 30 kg/m²
- B. Brownish skin thickening on the neck
- C. Cholesterol level
- D. Round 3x3 mm pale pink mole
Correct Answer: B
Rationale: Brownish skin thickening on the neck may indicate acanthosis nigricans, associated with insulin resistance or diabetes, requiring prompt reporting.
The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply.
- A. I should rinse my mouth with water before collecting the sputum.
- B. I will be careful not to touch the inside of the specimen cup or lid.
- C. I will inhale deeply a few times and then cough forcefully.
- D. It is best to collect the sputum mid-day when my secretions are loose.
- E. It is helpful if I am sitting upright when I collect the sputum.
Correct Answer: A,B,C,E
Rationale: Rinsing the mouth, avoiding contamination, deep coughing, and sitting upright ensure a quality specimen. Morning collection is preferred for higher yield.
The pediatric nurse receives report on 4 clients. Which client should the nurse see first?
- A. A 2-month-old awaiting evaluation for possible hip dislocation; parents are at the bedside
- B. A 6-year-old just returned from a bronchoscopy; a parent is at the bedside
- C. A 7-year-old just returned from a non-contrast abdominal CT scan; no parents are at the bedside
- D. An 11-year-old scheduled for ear surgery today, no parents are at the bedside
Correct Answer: B
Rationale: The 6-year-old post-bronchoscopy is at risk for airway complications and requires immediate assessment.