Nokea
The mother calls the nurse to report that her toddler has just been burned on the arm. The nurse should advise the mother to first:
- A. Pack the arm in ice, then take the child to the closest emergency department.
- B. Rub the burned area with an antibacterial ointment, then call the doctor.
- C. Run cool water over the burned area, then wrap it in a clean cloth.
- D. Call the child's health care provider immediately, then wrap the arm in a clean cloth.
Correct Answer: C
Rationale: Running cool water over the burn reduces tissue damage and pain, followed by wrapping in a clean cloth to protect the area before seeking medical care.
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The nurse providing emergency treatment for a client in ventricular tachycardia is preparing to defibrillate the client. Which nursing action provides for the safest environment during a defibrillation attempt?
- A. Ensuring that no lubricant is on the paddles
- B. Placing the charged paddles one at a time on the client's chest
- C. Holding the client's upper torso stable while the defibrillation is performed
- D. Assuring that all assisting personnel are clear of the client and the client's bed
Correct Answer: D
Rationale: Safety during defibrillation is essential for preventing injury to the client and the personnel assisting with the procedure. The person performing the defibrillation ensures that all personnel are standing clear of the bed by a verbal and visual check of 'all clear.' For the shock to be effective, some type of conductive medium (e.g., lubricant, gel) must be placed between the paddles and the skin. Both paddles are placed on the client's chest.
The nurse is caring for a client who has just undergone a coronary artery bypass graft (CABG). Which of the following interventions is most important in the immediate postoperative period?
- A. Monitor for signs of bleeding.
- B. Encourage deep breathing exercises.
- C. Administer oral pain medications.
- D. Restrict all visitors.
Correct Answer: A
Rationale: Monitoring for bleeding is critical post-CABG due to the risk of hemorrhage from the surgical site or anticoagulation therapy.
A 7-year-old child is admitted to the hospital with acute rheumatic fever. When discussing long-term care for the child with the parents, the nurse should teach them that a necessary part of this care is:
- A. Physical therapy.
- B. Antibiotic therapy.
- C. Psychological therapy.
- D. Anti-inflammatory therapy.
Correct Answer: B
Rationale: Antibiotic therapy is essential for acute rheumatic fever to eradicate streptococcal infection and prevent recurrence, which is critical for long-term management.
The nurse should question which medication if prescribed for a client diagnosed with an inoperable ruptured intracranial aneurysm?
- A. Nicardipine
- B. Heparin sodium
- C. Docusate sodium
- D. Aminocaproic acid
Correct Answer: B
Rationale: The nurse should question a prescription for heparin sodium, which is an anticoagulant. This medication could place the client at risk for rebleeding. Nicardipine is a calcium channel-blocking agent that is useful in the management of vasospasm associated with cerebral hemorrhage. Docusate sodium is a stool softener, which helps prevent straining. Straining would raise intracranial pressure. Aminocaproic acid is an antifibrinolytic agent that prevents clot breakdown or dissolution. It may be prescribed after ruptured intracranial aneurysm and subarachnoid hemorrhage if surgery is delayed or contraindicated.
A nurse is preparing to administer a blood transfusion. Which of the following actions should be taken to verify the blood product? Select all that apply.
- A. Check the client's blood type with another nurse
- B. Verify the client's wristband identification
- C. Ensure the blood bag is labeled with the client's name
- D. Confirm the expiration date on the blood bag
- E. Match the blood type on the bag with the physician's order
Correct Answer: A,B,D,E
Rationale: Two nurses must verify the client's blood type, wristband, blood bag expiration, and match the blood type to the order to prevent transfusion reactions. The bag is labeled with a unit number, not the client's name.