Nokea
Place the following interventions in the correct order.
- A. Apply a loose, sterile, bulky dressing
- B. Give pain medication
- C. Remove the victim from the cold environment
- D. Immerse the feet in warm water 100°F to 105°F (40.6°C to 46.1°C)
Correct Answer: C
Rationale: The first priority is removing the victim from the cold environment to prevent further damage.
You may also like to solve these questions
An 80-year-old patient is placed in isolation when infected with methicillin-resistant Staphylococcus aureus. The patient was alert and oriented on admission, but is now having visual hallucinations and can follow only simple directions. The medical-surgical nurse recognizes that the changes in the patient's mental status are related to
- A. a fluid and electrolyte imbalance.
- B. a stimulating environment.
- C. sensory deprivation.
- D. sundowning.
Correct Answer: C
Rationale: Isolation can lead to sensory deprivation, affecting cognitive function.
On the first postoperative day following a bowel resection, the patient complains of abdominal and incisional pain rated 9 on a scale of 0 to 10. Postoperative orders include morphine, 4 mg IV q2 hr, for pain and may repeat morphine, 4 mg IV, for breakthrough pain. The nurse determines that it has been only 2 hours since the last dose of morphine and wants to wait a little longer. What effect does the nurse’s action have on the patient?
- A. Protects the patient from addiction and toxic effects of the drug
- B. Prevents hastening or causing a patient’s death from respiratory dysfunction
- C. Contributes to unnecessary suffering and physical and psychosocial dysfunction
- D. Indicates that the nurse understands the adage of “start low and go slow” in administering analgesics
Correct Answer: C
Rationale: The correct answer is C. Delaying pain relief contributes to unnecessary suffering and can negatively impact recovery.
Which of the following is a definitive sign of pregnancy?
- A. Amenorrhea
- B. Positive hCG
- C. Morning sickness
- D. Fetal heart sounds
Correct Answer: D
Rationale: Fetal heart sounds are a definitive sign of pregnancy, confirming the presence of a viable fetus.
Which type of stress helps individuals pursue goals and solve problems?
- A. Energy stress
- B. Active stress
- C. Eustress
- D. Distress
Correct Answer: C
Rationale: Eustress is positive stress that motivates individuals to achieve goals, learn new skills, and manage crises effectively.
The nurse has been assigned to these clients in the emergency room. Which client would the nurse go check first?
- A. Viral pneumonia with atelectasis.
- B. Spontaneous pneumothorax with a respiratory rate of 38.
- C. Tension pneumothorax with slight tracheal deviation to the right.
- D. Acute asthma with episodes of bronchospasm.
Correct Answer: C
Rationale: Tension pneumothorax is a life-threatening condition requiring immediate attention.