Nokea
Following a disaster with multiple victims and danger to those present, which group should have priority for protection from injury?
- A. The clients/victims.
- B. The firefighters and police officers.
- C. The bystanders and news reporters.
- D. The healthcare providers.
Correct Answer: B
Rationale: Firefighters and police officers (B) have priority for protection as they are essential for managing the disaster and ensuring safety for others. Victims (A), bystanders (C), and healthcare providers (D) follow in priority.
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The nurse is caring for an organ donor client with a severe head injury from an MVA. Which of the following is most important when caring for the organ donor client?
- A. Maintenance of the BP at 90 mmHg or greater
- B. Maintenance of a normal temperature
- C. Keeping the hematocrit at less than 28%
- D. Ensuring a urinary output of at least 300 mL/hr
Correct Answer: A
Rationale: Maintaining BP at 90 mmHg or greater ensures organ perfusion, critical for organ viability in a donor. Normal temperature and adequate urine output are important, but BP is the priority. Low hematocrit is not a goal.
A client has been diagnosed with glossopharyngeal neuralgia. The nurse will expect the client to
- A. experience episodes of vertigo.
- B. experience difficulty moving the tongue.
- C. experience double vision.
- D. experience episodes of pain in the throat, ears, tongue, and tonsils.
Correct Answer: D
Rationale: Glossopharyngeal neuralgia causes severe pain in the throat, ears, tongue, and tonsils due to irritation of the ninth cranial nerve.
A client is admitted with suspected acute pancreatitis. Which lab finding confirms the diagnosis?
- A. Blood glucose of 260 mg/dL
- B. White cell count of 21,000 cu/mm
- C. Platelet count of 250,000 cu/mm
- D. Serum amylase level of 600 units/dL
Correct Answer: D
Rationale: Elevated serum amylase levels, particularly above 3 times the normal range, confirm acute pancreatitis due to pancreatic enzyme release.
The nurse has just administered morphine 4 mg IV to a client with severe pain from a kidney stone. The client then asks to get up to the toilet. Which is the correct nursing action for this client?
- A. assist the client to the toilet
- B. offer the client a bedpan or urinal
- C. obtain an order for a Foley catheter
- D. place a bedside commode in the room
Correct Answer: B
Rationale: Morphine can cause sedation and dizziness, increasing fall risk. Offering a bedpan or urinal is safer than ambulating to the toilet.
The nurse is caring for a client scheduled for removal of the pituitary gland. The nurse should be particularly alert for:
- A. Nasal congestion
- B. Abdominal tenderness
- C. Muscle tetany
- D. Oliguria
Correct Answer: D
Rationale: Oliguria may indicate diabetes insipidus, a common complication after pituitary surgery due to antidiuretic hormone deficiency.