Nokea
The home health nurse is planning for the day's visits. Which client should be seen first?
- A. The 78-year-old who had a gastrectomy 3 weeks ago with a PEG tube
- B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension
- C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line
- D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter
Correct Answer: D
Rationale: The priority client is the 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter. This client is at the highest risk for complications and requires immediate attention. Choice C, the 50-year-old with MRSA being treated with Vancomycin via a PICC line, is incorrect as Vancomycin administration can be scheduled at specific times and does not indicate an urgent need for a visit. Choices A and B are also incorrect as these clients are more stable compared to the client with multiple sclerosis in need of cortisone therapy.
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In the emergency room, a nurse is responsible for triaging four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care?
- A. A 10-year-old with lacerations on the face
- B. A 15-year-old with sternal bruises
- C. A 34-year-old with a fractured femur
- D. A 50-year-old with a dislocated elbow
Correct Answer: B
Rationale: The 15-year-old with sternal bruises should receive priority in care as this client might be experiencing airway and oxygenation problems. Airway issues take precedence in triage. The 10-year-old with lacerations on the face, although looking bad, is not in immediate distress. The 34-year-old with a fractured femur should be immobilized but can be seen after the client with sternal bruising. The 50-year-old with a dislocated elbow can also be seen later as dislocated elbows are not life-threatening compared to potential airway compromise.
The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical-surgical unit. Which group of clients should she assign to the medical-surgical nurse?
- A. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction
- B. C-section planning discharge, post-partum infection, mastectomy
- C. Vaginal delivery of fetal demise, C-section with pneumonia, 32-week gestation with lymphoma
- D. 28-week gestation of bed rest, post-partum with HELLP syndrome, breast reconstruction
Correct Answer: A
Rationale: The correct answer includes clients who have undergone surgical procedures typically managed on a medical-surgical unit. Choice A consists of clients who have had elective surgical procedures such as hysterectomy, bladder suspension with A&P repair, and breast reduction, which are commonly treated in a medical-surgical setting. Choices B, C, and D involve clients with various complications related to childbirth, fetal demise, pneumonia, gestational lymphoma, HELLP syndrome, and bed rest, which are more complex cases requiring specialized care beyond medical-surgical nursing.
The healthcare provider recognizes that which of the following would be most appropriate to wear when providing direct care to a client with a cough?
- A. Mask
- B. Gown
- C. Gloves
- D. Shoe covers
Correct Answer: A
Rationale: When providing care to a client with a cough, it is crucial to wear a mask to protect oneself from inhaling respiratory droplets containing infectious agents. The primary mode of transmission for coughs is through airborne droplets, making a mask the most appropriate choice to prevent the spread of respiratory infections. Gloves and gowns are more relevant when there is a risk of contact with bodily fluids, which is not the main concern with a cough. Shoe covers are not necessary in this scenario as the transmission of respiratory infections is not linked to footwear. Therefore, wearing a mask is the best choice to prevent airborne transmission and ensure the safety of the healthcare provider.
A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate?
- A. Blood pressure monitoring every 15 minutes
- B. Insertion of a Levine tube
- C. Continuous cardiac monitoring
- D. Administration of pain medication every 4 hours
Correct Answer: B
Rationale: In a client with pancreatitis who frequently experiences nausea and vomiting, insertion of a Levine tube is often anticipated to decompress the stomach and rest the bowel, helping to alleviate symptoms. This intervention is crucial in managing the gastrointestinal symptoms associated with pancreatitis. Blood pressure monitoring every 15 minutes may be necessary in some cases, but it is not a routine order for pancreatitis, making option A less likely. Continuous cardiac monitoring could be required based on the individual's condition, but it is not typically the first priority in pancreatitis management, so option C is not the most anticipated order. While pain medication administration is essential for managing discomfort, the priority in this scenario, especially considering the symptoms of nausea and vomiting, would be decompression with a Levine tube to address gastrointestinal issues, making option D less likely.
What is a common characteristic of a batterer?
- A. Grew up in a loving, secure home
- B. Was an only child
- C. Was physically or psychologically abused
- D. Admits they have a problem with anger
Correct Answer: C
Rationale: The correct answer is that a batterer is typically someone who was physically or psychologically abused. Research shows that many individuals who engage in abusive behavior report a history of being abused themselves. Choices A, B, and D are incorrect. While it is possible for a batterer to have grown up in a loving, secure home, been an only child, or acknowledge their anger issues, the most common factor associated with becoming a batterer is a history of being abused.