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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 caring for a client with a tracheostomy. Which of the following actions should the nurse perform to prevent complications?
- A. Suction the tracheostomy every 8 hours.
- B. Clean the inner cannula with sterile technique.
- C. Change the tracheostomy ties daily.
- D. Use a dry gauze dressing around the tracheostomy site.
Correct Answer: B
Rationale: Cleaning the inner cannula with sterile technique prevents infection and ensures airway patency, a priority in tracheostomy care. Suctioning (A) is as needed, not routine, tie changes (C) are less frequent, and dressings (D) should be pre-cut and moisture-resistant.
An adult is to go to surgery this morning. When the nurse goes to medicate the client, she notes that she has a ring with several shiny stones in it on her left ring finger. There are no relatives present. What is the best nursing action?
- A. Tape the ring before medicating the client.
- B. Ask the client to put the ring in the bedside drawer.
- C. Label the ring and place it in an envelope in the hospital safe.
- D. Have the client sign a waiver regarding responsibility for the ring.
Correct Answer: C
Rationale: Securing valuables in the hospital safe protects the ring during surgery, adhering to safety protocols. Taping, bedside storage, or waivers risk loss.
The top nursing priority includes:
- A. monitor the patient's v/s & notify the doctor stat
- B. Clear the patient's immediate environment & ask other clients to move away
- C. Place the patient in flat position and check her abdominal dressing.
- D. Get the crash cart in anticipation for cardiac arrest
Correct Answer: A
Rationale: Hypotension and tachycardia suggest postpartum hemorrhage, requiring immediate physician notification.
The nurse is assessing a client with suspected rheumatoid arthritis. Which of the following findings would support this diagnosis?
- A. Morning stiffness lasting over 30 minutes.
- B. Heberden’s nodes on the fingers.
- C. Pain in a single joint after exercise.
- D. Fever and weight loss without joint pain.
Correct Answer: A
Rationale: Morning stiffness lasting over 30 minutes is a hallmark of rheumatoid arthritis due to synovial inflammation. Heberden’s nodes (B) indicate osteoarthritis, single-joint pain (C) suggests injury, and fever/weight loss (D) are nonspecific without joint involvement.
Appropriate patient teaching when the chest tube is removed:
- A. Instruct the patient take deep breath and hold it during removal.
- B. Inform the patient that this is not a painful procedure.
- C. Ensure that the site is covered with a loose, dry dressing.
- D. Expect tachypnea after the removal.
Correct Answer: A
Rationale: Holding a deep breath during removal prevents air entry into the pleural space.