Nokea
Multiple clients have been brought to the emergency department after being struck by lightning during a severe thunderstorm. Which of the following clients should the nurse prioritize? The client who?
- A. reports numbness and tingling in all their extremities.
- B. has paralysis on both lower extremities.
- C. is confused and cannot remember their name or why they are in the emergency department.
- D. experienced a massive electrical current discharge to their body.
Correct Answer: B
Rationale: Paralysis in both lower extremities indicates potential spinal cord injury or severe neurological damage, requiring immediate prioritization. Numbness and tingling (A) suggest peripheral nerve issues, confusion (C) may indicate concussion or hypoxia, and massive discharge (D) lacks specific clinical urgency without symptoms.
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A client with bladder cancer reports fatigue and weight loss. The nurse should assess for:
- A. Metastasis.
- B. Dehydration.
- C. Infection.
- D. Anemia.
Correct Answer: A
Rationale: Fatigue and weight loss in bladder cancer may indicate metastasis, as the disease progresses.
A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which of the following indicates this client is ready to be discharged?
- A. The client voids 500 mL of urine.
- B. The client tolerates eating a hamburger.
- C. The client is pain-free.
- D. The client walks in the hallway unassisted.
Correct Answer: A
Rationale: Voiding 500 mL indicates normal bladder function, a key discharge criterion after hernia repair, ensuring no urinary retention from anesthesia or surgery.
The nurse has reinforced education at a conference on intramuscular (IM) injections. Which of the following statements by the participant would indicate a correct understanding of the teaching?
- A. "1 mL is the maximum volume in a single site for small children and older infants."
- B. "Depress the plunger as the needle is being inserted into the client's skin to minimize discomfort."
- C. "Insert the needle quickly using a dart-like motion at a 60-degree angle."
- D. "Injecting in the ventrogluteal muscle is more painful than the vastus lateralis."
Correct Answer: A
Rationale: The maximum volume for IM injections in small children and older infants is 1 mL to prevent tissue damage; other options contain incorrect techniques or assumptions.
A client uses a metered-dose inhaler (MDI) to aid in management of his asthma. Which action by the client indicates to the nurse that he needs further instruction regarding its use? Select all that apply.
- A. Activation of the MDI is not coordinated with inspiration.
- B. The client inspires rapidly when using the MDI.
- C. The client holds his breath for 3 seconds after inhaling with the MDI.
- D. The client shakes the MDI after use.
- E. The client performs puffs in rapid succession.
Correct Answer: A,B,C,E
Rationale: Incorrect MDI use includes not coordinating activation with inspiration (A), rapid inspiration (B), holding breath for only 3 seconds (C; should be 10 seconds), and rapid successive puffs (E; wait 1 minute between puffs). Shaking after use (D) is incorrect but less critical.
A 42-year-old female is interested in making dietary changes to reduce her risk of colon cancer. What dietary selections should the nurse suggest?
- A. Croissant, granola and peanut butter squares, whole milk.
- B. Bran muffin, skim milk, stir-fried broccoli.
- C. Granola, bagel with cream cheese, cauliflower salad.
- D. Oatmeal, raisin cookies, baked potato with sour cream, turkey sandwich.
Correct Answer: B
Rationale: A diet high in fiber (bran muffin, broccoli) and low in fat (skim milk) reduces colon cancer risk by promoting healthy digestion and reducing carcinogenic exposure in the colon.