Nokea
The home health nurse is assessing a client in their home with suspected carbon monoxide poisoning. The nurse should take which priority action?
- A. Move the client outdoors
- B. Notify the primary healthcare provider (PHCP)
- C. Auscultate the client's lung sounds
- D. Assess the client's pulse oximetry
Correct Answer: A
Rationale: Moving the client outdoors (A) is the priority to remove them from the carbon monoxide source, preventing further toxicity. Notifying the PHCP (B), auscultating lungs (C), and assessing oximetry (D) follow after ensuring safety, as oximetry may be falsely normal in CO poisoning.
You may also like to solve these questions
The nurse is caring for assigned clients. The nurse should immediately follow-up on the client who
- A. is being treated for pneumonia and develops restlessness.
- B. is receiving intravenous fluids for influenza and dehydration and reports a headache.
- C. has a chest drainage system in place for a hemothorax and tidaling is present in the water seal chamber.
- D. is being treated for pleurisy and is experiencing inspiratory chest pressure.
Correct Answer: A
Rationale: Restlessness in pneumonia (A) may indicate hypoxia, requiring immediate follow-up. Headache with fluids (B), tidaling in chest tube (C), and pleurisy pain (D) are expected or less urgent.
The nurse is developing a care plan for a client with Bell's palsy. Which problem should the nurse prioritize in the care plan?
- A. Risk for infection
- B. Risk for disturbed sensory perception
- C. Risk for disturbed body image
- D. Risk for ineffective tissue perfusion
Correct Answer: B
Rationale: Risk for disturbed sensory perception (B) is the priority in Bell’s palsy due to facial paralysis, which can lead to corneal abrasion or oral injury. Infection (A), body image (C), and perfusion (D) are secondary concerns.
During a bath, the unlicensed assistive personnel (UAP) reports to the nurse that the client has malodorous discharge from the gastrostomy tube. The nurse should initially
- A. obtain a specimen for culture.
- B. assess the drainage.
- C. place a sterile dressing around the gastrostomy tube.
- D. assess the client's temperature for fever.
Correct Answer: B
Rationale: Assessing the drainage (B) is the first step to determine the cause, such as infection or tube malfunction, guiding further action. Obtaining a culture (A), applying a dressing (C), or checking for fever (D) are secondary without initial assessment data.
The registered nurse (RN) assigns client care to a licensed practical/vocational nurse (LPN/VN). Which of the following clients should the RN assign to the LPN? Select all that apply. A client
- A. requiring an assessment of their current prescribed medications.
- B. needing a nasogastric tube (NGT) for enteral feedings.
- C. with an insulin pump and is unsure of how to load the insulin.
- D. with unstable blood pressure following adrenalectomy.
- E. requiring airborne isolation and bronchodilators via an inhaler.
Correct Answer: B, E
Rationale: Administering enteral feedings via NGT (B) and bronchodilators via inhaler (E) are within the LPN’s scope for stable clients. Medication assessment (A), insulin pump teaching (C), and unstable BP post-adrenalectomy (D) require RN-level judgment due to complexity or instability.
The emergency department (ED) nurse is caring for a client with suspected bacterial meningitis. The nurse should take which priority action?
- A. Notify public health services
- B. Dim the lights in the assigned room
- C. Obtain blood cultures
- D. Explore the client's feelings regarding the diagnosis
Correct Answer: C
Rationale: Obtaining blood cultures (C) is the priority action for suspected bacterial meningitis to confirm the diagnosis and guide antibiotic therapy. While droplet precautions (not listed) are also critical to prevent spread, cultures are the most urgent among the options. Notifying public health (A) is secondary, dimming lights (B) addresses comfort, and exploring feelings (D) is not a priority in an acute infection.