Nokea
In the Emergency Department (ED), which client should the nurse see first?
- A. COPD client with a non-productive cough
- B. Diabetic client who has an infected sore on the foot
- C. Client with adrenal insufficiency who feels weak
- D. Client with a fracture of the forearm in an air splint
Correct Answer: C
Rationale: In the Emergency Department, the priority is to assess and manage clients based on the urgency of their conditions. A client with adrenal insufficiency presenting with weakness should be seen first as this could indicate a state of shock, which requires immediate attention to stabilize the client's condition. Weakness in adrenal insufficiency can progress rapidly to a life-threatening adrenal crisis. Choice A, a COPD client with a non-productive cough, may need treatment but is not immediately life-threatening. Choice B, a diabetic client with an infected sore on the foot, requires timely care to prevent complications but can generally wait for evaluation compared to the potential urgency of adrenal insufficiency. Choice D, a client with a fracture of the forearm in an air splint, is important but not as time-sensitive as a client potentially in shock.
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The nurse is preparing for a dressing change on a full thickness burn to the flank area. The orders include irrigating the wound with each dressing change. To irrigate the wound, what will the nurse use?
- A. Sterile saline
- B. Distilled water
- C. Betadine scrub
- D. Tap water
Correct Answer: A
Rationale: When irrigating a wound, especially in the case of a full-thickness burn, it is crucial to use a solution that is gentle and non-irritating to the tissues. Sterile saline is the preferred choice for wound irrigation as it is isotonic and does not cause additional damage to the already compromised tissue. Distilled water lacks the electrolytes present in saline, Betadine scrub is not used for irrigation due to its potential to be cytotoxic, and tap water may introduce contaminants and microorganisms to the wound.
While Fluorouracil (5FU®) is being infused, a client complains of burning at the IV site. What should the nurse do first?
- A. Aspirate the IV site for blood return.
- B. Slow the infusion.
- C. Inspect the IV site.
- D. Stop the infusion.
Correct Answer: C
Rationale: The correct first action for the nurse is to inspect the IV site. This is important to assess for any signs of infiltration or extravasation, which could be causing the burning sensation. Aspirating the IV site for blood return (Choice A) may not be the initial priority as it does not directly address the client's complaint of burning. Slowing the infusion (Choice B) may help alleviate discomfort but should not be done before inspecting the site. Stopping the infusion (Choice D) may be necessary, but inspecting the site should come first to determine the appropriate course of action.
The nurse observes a nursing assistant performing AM care for a client with a new leg cast. Which action by the assistant will the nurse intervene?
- A. Lifting the affected leg with the palms of the hands
- B. Covering the affected leg with a blanket to avoid chills
- C. Placing plastic over the groin prior to bathing
- D. Elevating the casted leg on two pillows
Correct Answer: B
Rationale: The correct answer is to intervene when the assistant covers the affected leg with a blanket to avoid chills. A new cast should not be covered to allow the heat from the cast to evaporate, preventing complications. Lifting the affected leg with the palms of the hands is appropriate for proper handling. Placing plastic over the groin prior to bathing is a standard practice to protect the client's privacy and maintain hygiene. Elevating the casted leg on two pillows helps reduce swelling and promote circulation, making it a suitable action.
After a client has a tubal ligation in the outpatient surgical clinic, what is the priority for the nurse to determine?
- A. The client's prior experiences with outpatient surgery
- B. The client's medical plan and the extent of coverage for outpatient surgery
- C. The client's plan for transportation and care at home
- D. The client's plan to spend the night at the surgical center
Correct Answer: C
Rationale: The priority for the nurse is to ensure the client has a safe way to get home and adequate care after discharge. It is crucial to determine the client's transportation arrangements and availability of care at home to ensure a smooth transition postoperatively. Options A and B, though important, are not immediate priorities compared to the client's safety and well-being after the procedure. Option D is incorrect as spending the night at the surgical center is not typically part of the plan for outpatient surgery.
Which infection control measure is the priority for the nurse to implement in the care provided for a child admitted to the hospital with bacterial meningitis?
- A. Place the child in a private room
- B. Gowns and masks must be worn by all personnel in the child's room
- C. Visitors are restricted to parents only
- D. Hand washing is required by all personnel and visitors having contact with the child
Correct Answer: B
Rationale: The priority control measure for the nurse to implement in caring for a child with bacterial meningitis is ensuring that gowns and masks are worn by all personnel in the child's room. This measure is crucial as the child with bacterial meningitis is contagious for at least 24 hours after starting antibiotics, necessitating airborne precautions to prevent the spread of infection to healthcare workers and other patients. Placing the child in a private room (Choice A) is important but secondary to preventing infection transmission. Restricting visitors to parents only (Choice C) is also significant but not as critical as ensuring proper infection control measures. While hand washing (Choice D) is essential, the immediate need to prevent airborne transmission in the child's room takes precedence.