Nokea
Nurse Kelly is teaching the parents of a young child how to handle poisoning. If the child ingests poison, what should the parents do first?
- A. Administer ipecac syrup
- B. Call an ambulance immediately
- C. Call the poison control center
- D. Punish the child for being bad
Correct Answer: C
Rationale: Calling the poison control center provides immediate guidance on how to handle the specific type of poisoning and whether further medical intervention is needed.
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A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client plan of care?
- A. Continuous cardiac monitoring
- B. Perform passive range of motion
- C. Evaluate level of consciousness
- D. Assess lung sounds q4 hours.
Correct Answer: A
Rationale: Electrical injuries can cause cardiac arrhythmias, so continuous cardiac monitoring is critical to detect and manage any life-threatening complications.
List THREE indications for intervention for aortopathy in Marfan’s syndrome in an older teenager.
- A. Aortic root or ascending aorta dilation >44-50mm
- B. Symptomatic (pain consistent with rupture)
- C. Growth of >0.5cm/y
- D. All of the above
Correct Answer: D
Rationale: These are significant indicators that require surgical intervention to prevent further complications, such as rupture or dissection.
Peak expiratory flow rate:
- A. Is a sensitive parameter to assess improvement to therapy in acute bronchial asthma
- B. Measures small airway resistance
- C. Is more related to height rather than age
- D. Less than 50% of normal is an indication for aminophylline therapy in acute asthma
Correct Answer: A
Rationale: Peak expiratory flow rate is a useful tool to monitor response to asthma therapy, particularly in acute exacerbations.
The most common indication of heart transplantation in the neonate is
- A. Hypoplastic left heart syndrome
- B. Hypoplastic right heart syndrome
- C. Severe Ebstein's anomaly
- D. Dilated cardiomyopathy
Correct Answer: A
Rationale: Hypoplastic left heart syndrome is the most common indication for heart transplantation in neonates.
An older client is admitted after falling while walking. The left leg is externally rotated and shorter than the right leg, and the client is having severe pain and tingling in the left foot. The nurse is unable to palpate the left pedal pulses. Which action is most important for the nurse to implement?
- A. Use a doppler to assess bilateral pedal pulses
- B. Administer pain medication to relieve discomfort.
- C. Position the client’s left leg in a neutral position to reduce pain.
- D. Immobilize the left leg to prevent further injury.
Correct Answer: A
Rationale: Assessing pedal pulses with a doppler is critical to evaluate circulation and detect potential vascular compromise in the affected limb.