Nokea
The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 68/34, pulse rate 130, and respirations 18. Which is the client's most appropriate priority nursing diagnosis?
- A. Alteration in cerebral tissue perfusion
- B. Fluid volume deficit
- C. Ineffective airway clearance
- D. Alteration in sensory perception
Correct Answer: B
Rationale: The vital signs indicate hypovolemic shock, making fluid volume deficit the priority nursing diagnosis.
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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.
The nurse is caring for an adolescent with a 5-year history of bulimia. A common clinical finding in the client with bulimia is:
- A. Extreme weight loss
- B. Dental caries
- C. Hair loss
- D. Decreased temperature
Correct Answer: B
Rationale: Dental caries are common in bulimia due to frequent vomiting, which exposes teeth to stomach acid, causing enamel erosion.
The nurse is caring for a client with uremic frost. The nurse is aware that uremic frost is often seen in clients with:
- A. Severe anemia
- B. Arteriosclerosis
- C. Liver failure
- D. Parathyroid disorder
Correct Answer: C
Rationale: Uremic frost, a powdery deposit on the skin, is associated with end-stage renal failure, not liver failure, but the options suggest a contextual error; renal failure is the intended association.
A nurse working in ICU has a client on a propofol (Diprivan) drip while on the mechanical ventilator. The nurse needs another bottle, which must be picked up in person in the hospital pharmacy. Which is the correct action by the nurse concerning this medication?
- A. ask the unit secretary to go to the pharmacy and pick it up
- B. send the unlicensed assistive personnel (UAP) to pick it up since the nurse is busy
- C. ask the client's health care provider to bring it when he or she rounds on the client
- D. ask another nurse to watch the clients while the nurse goes to the pharmacy to get the medication
Correct Answer: D
Rationale: The nurse must ensure continuous client monitoring, so asking another nurse to cover while retrieving the controlled medication is the safest action.
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
- A. Notify her.Concurrent doctor
- B. Increase the rate of IV fluid
- C. Reposition the client
- D. Readjust the monitor
Correct Answer: C
Rationale: Repositioning the client can relieve umbilical cord compression, the common cause of variable decelerations.