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The elderly client is brought to the ED complaining of cramps, headache, and weakness after working outside in the sun. The telemetry shows sinus tachycardia. Which intervention should the nurse implement?
- A. Determine if the client is experiencing any thirst.
- B. Administer D5W intravenously at 250 mL/hr.
- C. Maintain a cool environment to promote rest.
- D. Withhold the client’s oral intake.
Correct Answer: C
Rationale: Heat exhaustion (suggested by symptoms) requires a cool environment to reduce core temperature. Thirst assessment, D5W, and withholding intake are secondary or incorrect.
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The client has been brought to the ED by ambulance following a motor-vehicle accident with a flail chest, an intravenous line, and a Heimlich valve. Which intervention should the nurse implement first?
- A. Start a large-bore intravenous access.
- B. Request a portable chest x-ray.
- C. Prepare to insert chest tubes.
- D. Assess the cardiac rhythm on the monitor.
Correct Answer: C
Rationale: A flail chest with a Heimlich valve indicates a pneumothorax; preparing for chest tube insertion stabilizes breathing, the priority. Additional IVs, x-rays, and cardiac monitoring follow.
The elderly male client is admitted to the medical unit with a diagnosis of senile dementia. The client is 74 inches tall and weighs 54.5 kg. The client lives with his son and daughter-in-law, both of whom work outside the house. Which referral is most important for the nurse to implement?
- A. Adult Protective Services.
- B. Social worker.
- C. Medicare ombudsman.
- D. Dietitian.
Correct Answer: A
Rationale: Low weight (54.5 kg for 74 inches, BMI ~16.5) and dementia suggest potential neglect, warranting Adult Protective Services referral. Social work, ombudsman, and dietitian are secondary.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical unit. Which nursing task cannot be delegated to the UAP?
- A. Obtaining the intake and output on a client diagnosed with food poisoning.
- B. Performing a dressing change on the client with a chemical burn.
- C. Assisting a client who overdosed on morphine to the bedside commode.
- D. Help a client with carbon monoxide poisoning turn, cough, and deep breathe.
Correct Answer: B
Rationale: Dressing changes on chemical burns require assessment and sterile technique, a nursing task. Intake/output, ambulation, and turning are delegable to UAPs.
The charge nurse of the medical-surgical unit secured the crash cart during the code. Which intervention should the charge nurse implement after transferring the client to the intensive care unit?
- A. Reassign the clients on the floor because one is now gone.
- B. Call the family of the client who coded and let them know of the transfer.
- C. Make sure the crash cart is restocked.
- D. Hold a unit meeting to determine if anything could have been done differently during the code.
Correct Answer: C
Rationale: Restocking the crash cart ensures readiness for future emergencies, a priority post-code. Reassignment, family calls, and meetings are secondary.
The nurse in an outpatient rehabilitation facility is working with convicted child abusers. Which characteristics should the nurse expect to observe in the abusers? Select all that apply.
- A. The abuser calls the child a liar.
- B. The abuser has a tendency toward violence.
- C. The abuser exhibits a high self-esteem.
- D. The abuser is unable to admit the need for help.
- E. The abuser was spoiled as a child.
Correct Answer: A,B,D
Rationale: Child abusers often deny accusations (calling the child a liar), exhibit violence, and resist help due to denial. Low self-esteem is more common, and being spoiled is not typical.