Nokea
During a report from an ER nurse about a client, the nurse identifies a statement that requires additional follow-up. Which of the following statements needs further clarification?
- A. "The client said they have been taking aspirin, but I'm not sure for how long or how much."?
- B. "The client frequently takes antacids, but they have not taken any in the last three days."?
- C. "The client stopped taking ibuprofen after developing gastric ulcers."?
- D. "The client takes Antabuse and has stopped using mouthwash."?
Correct Answer: A
Rationale: The correct answer requires further follow-up as the nurse needs to know the duration and dosage of aspirin since it can impact the patient's bleeding risk. Choice B does not require immediate follow-up as not taking antacids for three days is not critical. Choice C indicates a necessary decision made by the client to stop ibuprofen after developing gastric ulcers, hence no immediate follow-up is needed. Choice D provides important information, but the priority is to address the lack of specificity regarding the client's aspirin use, which is crucial for assessing bleeding risk and potential interactions.
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What is the most appropriate intervention for a client with suspected genitourinary trauma and visible blood at the urethral meatus?
- A. Insertion of a Foley catheter.
- B. In-and-out catheter specimen for urinalysis.
- C. A voided urine specimen for urinalysis.
- D. A urologist consult.
Correct Answer: D
Rationale: A urologist consult is the most appropriate intervention for a client with visible blood at the urethral meatus and suspected genitourinary trauma. This specialist can evaluate the extent of the trauma and provide the necessary treatment. Foley catheter insertion (Choice A) and in-and-out catheter specimen for urinalysis (Choice B) are contraindicated in the presence of genitourinary trauma as they can worsen the injury. While a voided urine specimen for urinalysis (Choice C) may be ordered by the physician, it does not address the specific management needed for genitourinary trauma. Therefore, a urologist consult is the best option in this scenario.
Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes serosanguinous drainage on the dressing. The most appropriate intervention is to:
- A. notify the physician of the drainage
- B. change the dressing
- C. reinforce the dressing
- D. apply an abdominal binder
Correct Answer: C
Rationale: In the context of a classic cholecystectomy resection, serosanguinous drainage is an expected finding postoperatively due to the nature of the surgery. The appropriate intervention in this situation is to reinforce the dressing. Changing the dressing prematurely can increase the risk of introducing infection. Applying an abdominal binder is not recommended as it can obstruct the visualization of the dressing and the underlying wound, making it difficult to monitor for any complications or changes in drainage. Notifying the physician may be necessary if there are significant changes in the drainage characteristics or other concerning signs, but the immediate action should be to reinforce the dressing to maintain a clean and secure environment for wound healing.
When administering a nasal spray medication, what should the client do before the medication is administered?
- A. The client should blow their nose gently before the medication is administered.
- B. The medication should be sprayed into the nostril.
- C. The medication should be administered as the client inhales.
- D. The client should sit upright when the medication is administered.
Correct Answer: A
Rationale: The correct answer is that the client should blow their nose gently before the medication is administered. This step helps clear the nasal passages, ensuring that the medication can reach its intended target. Choice B is incorrect as the nasal spray should be directed into the nostril, not just in front of the nose. Administering the medication as the client inhales (Choice C) is crucial to ensure proper delivery, as it helps the medication reach the desired areas. Choice D is incorrect because the client should be sitting upright, not lying flat, when administering nasal spray medication to allow for better absorption and prevent the medication from flowing out.
The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine?
- A. 6
- B. 8
- C. 12
- D. 16
Correct Answer: C
Rationale: An 18-month-old child should have approximately 12 teeth. Children typically start getting teeth around 6 months of age. By subtracting 6 from the number of months in the child's age, you can calculate the expected number of teeth. For an 18-month-old child, 18 - 6 = 12 teeth. Therefore, the correct answer is 12 teeth. Choices A, B, and D are incorrect because they do not align with the expected dental development in an 18-month-old child.
Which of the following physical findings indicates that an 11-12-month-old child is at risk for developmental dysplasia of the hip?
- A. refusal to walk
- B. not pulling to a standing position
- C. negative Trendelenburg sign
- D. negative Ortolani sign
Correct Answer: B
Rationale: The correct answer is 'not pulling to a standing position.' If an 11-12-month-old child is unable to pull to a standing position, it can indicate a risk for developmental dysplasia of the hip. By 15 months of age, children should be walking, so delayed standing can be a red flag. The Trendelenburg sign is associated with gluteus medius muscle weakness, not hip dysplasia, making choice C incorrect. The Ortolani sign is used to detect congenital hip subluxation or dislocation, not developmental dysplasia, making choice D incorrect.