Nokea
The client is admitted following cast application for a fractured ulna. Which finding should be reported to the doctor?
- A. Pain at the site
- B. Warm fingers
- C. Pulses rapid
- D. Paresthesia of the fingers
Correct Answer: D
Rationale: Paresthesia of the fingers suggests possible nerve compression or compartment syndrome, which requires immediate reporting to the doctor.
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Which clients can be assigned to share a room in the emergency department during the disaster?
- A. A client having auditory hallucinations and the client with ulcerative colitis
- B. The client who is pregnant and the client with a broken arm
- C. A child who is cyanotic with severe dypsnea and a client with a frontal head injury
- D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain
Correct Answer: B
Rationale: The pregnant client and the client with a broken arm have stable conditions, making them suitable to share a room.
An obstetric client is admitted with dehydration. Which IV fluid would be most appropriate for the client?
- A. .45 normal saline
- B. Dextrose 1% in water
- C. Lactated Ringer's
- D. Dextrose 5% in .45 normal saline
Correct Answer: C
Rationale: Lactated Ringer's is isotonic and effective for correcting dehydration in obstetric clients, replacing fluids and electrolytes.
A labor and delivery nurse is assessing a newborn baby boy. Which finding would indicate possible microcephaly?
- A. depressed fontanelles during feeding
- B. hypoactivity
- C. head circumference in lowest tenth percentile
- D. absent fontanelles
Correct Answer: C
Rationale: Microcephaly is defined by a head circumference significantly below normal (e.g., lowest 10th percentile), indicating potential brain development issues.
Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
- A. Record the pulse rate and administer the medication
- B. Administer the medication and monitor the heart rate
- C. Withhold the medication and notify the doctor
- D. Withhold the medication until the heart rate increases
Correct Answer: C
Rationale: A pulse rate below 60 bpm is a contraindication for digoxin administration due to the risk of worsening bradycardia, so the nurse should withhold the dose and notify the physician.
Which of the following is a core measure set developed by the Joint Commission?
- A. genetics
- B. lymphoma
- C. nosocomial infections
- D. heart failure
Correct Answer: D
Rationale: Heart failure is a Joint Commission core measure set, focusing on improving care quality for common conditions. The others are not core measures.