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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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A nurse's neighbor complains of severe right flank pain. She explains that it began during the night, but she was able to take acetaminophen (Tylenol) and return to bed. When she awoke, the pain increased in intensity. How should the nurse intervene?
- A. Explain that she can't give medical advice
- B. Inform the neighbor that she might require surgery
- C. Advise the neighbor to seek medical attention
- D. Tell the neighbor that she'll be fine because she was able to get through the night
Correct Answer: C
Rationale: The nurse should advise the neighbor to seek medical attention. Explaining that she can't give medical advice might cause a delay in treatment. It's beyond the nurse's scope of practice to suggest that the neighbor might need surgery. Telling the neighbor she'll be fine might also delay treatment, and it isn't a professional response.
A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility. To which staff member should the charge nurse assign the client?
- A. Unlicensed assistive personnel (UAP)
- B. Senior nursing student
- C. PN
- D. RN
Correct Answer: D
Rationale: The RN is responsible for teaching and assessment associated with discharge and these activities cannot be delegated to the others listed.
A client is being admitted with a diagnosis of possible pancreatitis. Which of the following is the best support for this diagnosis?
- A. Pain is in the left upper quadrant of the abdomen
- B. Client reports steatorrhea for the last 3 days
- C. A serum amylase level of 366 U/L
- D. Assessed diminished bowel sounds
Correct Answer: C
Rationale: The client's amylase level is elevated above the normal level of 200 U/L. This measurement is the most accurate indicator of pancreatitis and the most objective and specific. The answers in A, B, and D are also clinical manifestations of pancreatitis, but are not as specific as the laboratory value, so they are incorrect choices.
A client who had a total thyroidectomy this morning is to be admitted to the surgical floor. What should the nurse have readily available when the client arrives?
- A. Tracheostomy set
- B. Catheterization tray
- C. Sterile dressing set
- D. Ventilator
Correct Answer: A
Rationale: Thyroidectomy risks airway obstruction from swelling or hematoma; a tracheostomy set is essential for emergency airway management.
Which interventions are appropriate when caring for a client with acute thrombophlebitis?
- A. Apply cool soaks and keep the client's leg lower than the level of the heart
- B. Increase the client's activity level and encourage leg exercises
- C. Apply cool soaks and administer nitroglycerin
- D. Apply warm soaks and elevate the client's legs higher than the level of the heart
Correct Answer: D
Rationale: To help treat thrombophlebitis, the nurse should prevent venostasis with measures such as applying warm soaks and elevating the client's legs. The client should remain on bed rest during the acute phase, after which the client may begin to walk while wearing antiembolism stockings. Treatment for thrombophlebitis may also include anticoagulants to prolong clotting time.