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If a nurse accidentally punctures a finger with a needle after withdrawing blood from a client, which of the following actions should be carried out first?
- A. Notify a supervisor.
- B. Wash the puncture area with soap and water.
- C. Apply pressure to the wound.
- D. File an incident/injury report.
Correct Answer: B
Rationale: Washing the puncture with soap and water (B) is the first step to reduce infection risk. Other actions (A, C, D) follow.
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The nurse is caring for a client taking levothyroxine (Synthroid) for hypothyroidism. Which finding indicates a side effect of this medication?
- A. weight loss
- B. weight gain
- C. light sensitivity
- D. excessive sleepiness
Correct Answer: A
Rationale: Weight loss can indicate excessive levothyroxine dosing, as it increases metabolism, unlike the other options, which are not typical side effects.
The nurse is caring for clients on a respiratory unit. Upon receiving the following client reports, which client should be seen first?
- A. Client with emphysema expecting discharge
- B. Bronchitis client receiving IV antibiotics
- C. Bronchitis client with edema and neck vein distention
- D. COPD client with PO2 of 85
Correct Answer: C
Rationale: Edema and neck vein distention in a bronchitis client suggest heart failure, a critical condition requiring immediate assessment. The other clients are stable or less urgent.
Prochlorperazine maleate (Compazine) 10 mg IM has been ordered for a client. The client is also to receive Stadol 2 mg IM. Before administering these medications, the nurse should
- A. obtain respirations and temperature.
- B. dilute with 9 ml of NS.
- C. draw the medications in separate syringes.
- D. verify the route of administration.
Correct Answer: C
Rationale: Compazine should be considered incompatible in a syringe with all other medications
A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain?
- A. The pain will go away in a few days.
- B. The pain is due to peripheral nervous system interruptions. I will get you some pain medication.
- C. The pain is psychological because your foot is no longer there.
- D. The pain and itching are due to the infection you had before the surgery.
Correct Answer: B
Rationale: Phantom limb pain results from peripheral nervous system interruptions, and offering pain medication addresses the client's discomfort appropriately.
The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?
- A. The presence of scant bloody discharge
- B. Frequent urination
- C. The presence of green-tinged amniotic fluid
- D. Moderate uterine contractions
Correct Answer: C
Rationale: Green-tinged amniotic fluid indicates meconium, a sign of fetal distress requiring immediate reporting.