Nokea
The emergency department (ED) nurse cares for a child with epistaxis. Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Apply ice or a cold cloth to the bridge of the nose if the bleeding persists.
- B. Apply continuous pressure to the tip of the nose with thumb and forefinger for at least 10 minutes.
- C. Provide the child with a drink to wash away the taste of blood.
- D. Have the child sit up with the neck forward or erect.
- E. Evaluate the bleeding to determine the effectiveness of the interventions.
Correct Answer: D, B, A, E, C
Rationale: Correct order: Sit upright, apply pressure, apply ice if needed, evaluate bleeding, provide a drink last.
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The nurse is providing teaching to a client experiencing chronic constipation. Which of the following meals would be the best choice for this client in order to promote a bowel movement?
- A. steak and a baked potato
- B. brussels sprouts and a whole grain roll
- C. white rice with chicken
- D. ham sandwich with tomato soup
Correct Answer: B
Rationale: Brussels sprouts and whole grain rolls are high in fiber, promoting bowel movements.
The nurse is collecting data on a client who is taking prescribed digoxin and furosemide. Which finding requires follow-up?
- A. Night sweats and headache
- B. Vomiting and halos around lights
- C. Fatigue and dry, flaky skin
- D. Low blood pressure and dark urine
Correct Answer: B
Rationale: Vomiting and halos around lights are signs of digoxin toxicity, requiring immediate follow-up.
The nurse is caring for a client who has been prescribed sertraline. The nurse understands that this medication is prescribed for which of the following conditions?
- A. Major Depressive Disorder
- B. Attention Deficit Hyperactivity Disorder
- C. Obsessive-Compulsive Disorder
- D. Generalized Anxiety Disorder
- E. Bipolar Disorder
Correct Answer: A, C, D
Rationale: Sertraline, an SSRI, is indicated for Major Depressive Disorder, Obsessive-Compulsive Disorder, and Generalized Anxiety Disorder, but not for ADHD or Bipolar Disorder.
The charge nurse has received a change-of-shift report on the following clients in the maternity unit. The nurse should first assess the client who
- A. delivered a term newborn 2 days ago and reports sweating and increased urinary frequency
- B. is 15 weeks pregnant and is being treated for hyperemesis gravidarum and reports increased nausea following a meal
- C. is 32 weeks pregnant and admitted 2 hours ago with placenta previa, who reports increased lower back pain
- D. is in the first stage of labor, and the most recent fetal heart rate pattern showed early decelerations
Correct Answer: C
Rationale: Increased lower back pain in a client with placenta previa at 32 weeks suggests possible complications like bleeding, requiring immediate assessment.
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 6 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.” Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Diagnostic Results
Head and Neck Computed Tomography (CT) Scan with Contrast
1831: Bilateral convexity subarachnoid hemorrhage over the right frontal lobe.
Laboratory Results
1849: Hemoglobin (Hgb) 14 g/dL [Male: 14-18 g/dL Female: 12-16 g/dL]
Hematocrit (Hct) 42% [Male: 42-52% Female: 37-47%]
International Normalized Ratio (INR) 3.8 [0.9-1.2]
Platelets 140,000 mm3 [150,000-400,00 mm3]
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
Orders
• insert peripheral vascular access device
• serum type and screen
• transfuse two units of fresh frozen plasma
• perform a bedside swallow evaluation
• apply sequential compression devices
• obtain a complete metabolic panel (CMP)
The nurse transfused the prescribed fresh frozen plasma. Click to specify which assessment data is necessary after the transfusion of FFP.
- A. international normalized ratio
- B. activated thromboplastin time (aPTT)
- C. hematocrit
- D. vital signs
Correct Answer: A, D
Rationale: INR and vital signs are critical to assess the effectiveness of FFP in correcting coagulopathy and monitoring for transfusion reactions.