Nokea
The newborn nursery is filled to capacity. Which newborn should the nurse assess first?
- A. A three-hour-old just waking up after a period of sleep
- B. A two-day-old crying loudly
- C. A three-day-old two hours after circumcision
- D. A one-hour-old sucking his fist
Correct Answer: A
Rationale: The most critical time for assessment in a newborn is during the second period of reactivity, which occurs approximately 3-5 hours after delivery. During this phase, newborns are more likely to gag on mucus and aspirate, making it crucial for the nurse to assess their respiratory status first. Choice A indicates a newborn in this critical phase, requiring immediate assessment for potential airway compromise or respiratory distress. Choices B, C, and D do not present an immediate need for assessment related to airway compromise or respiratory distress.
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To determine the standards of care for the institution, the nurse should consult?
- A. Organizational Chart
- B. Personnel policies
- C. Policies and procedure manual
- D. Job descriptions
Correct Answer: C
Rationale: The correct answer is the 'Policies and procedure manual.' This manual outlines the policies and procedures that govern patient care within the institution, including the standards of care that healthcare providers are expected to follow. Consulting the policies and procedure manual ensures that the nurse is adhering to the established guidelines and protocols. Choices A, B, and D are incorrect because although they are important documents within an institution, they do not specifically define the standards of care for patient management. The organizational chart illustrates the hierarchy of the institution, personnel policies outline rules related to employees, and job descriptions detail specific roles and responsibilities, none of which directly define patient care standards.
The nurse is preparing for a dressing change on a full thickness burn to the flank area. The orders include irrigating the wound with each dressing change. To irrigate the wound, what will the nurse use?
- A. Sterile saline
- B. Distilled water
- C. Betadine scrub
- D. Tap water
Correct Answer: A
Rationale: When irrigating a wound, especially in the case of a full-thickness burn, it is crucial to use a solution that is gentle and non-irritating to the tissues. Sterile saline is the preferred choice for wound irrigation as it is isotonic and does not cause additional damage to the already compromised tissue. Distilled water lacks the electrolytes present in saline, Betadine scrub is not used for irrigation due to its potential to be cytotoxic, and tap water may introduce contaminants and microorganisms to the wound.
In the Emergency Department (ED), which client should the nurse see first?
- A. COPD client with a non-productive cough
- B. Diabetic client who has an infected sore on the foot
- C. Client with adrenal insufficiency who feels weak
- D. Client with a fracture of the forearm in an air splint
Correct Answer: C
Rationale: In the Emergency Department, the priority is to assess and manage clients based on the urgency of their conditions. A client with adrenal insufficiency presenting with weakness should be seen first as this could indicate a state of shock, which requires immediate attention to stabilize the client's condition. Weakness in adrenal insufficiency can progress rapidly to a life-threatening adrenal crisis. Choice A, a COPD client with a non-productive cough, may need treatment but is not immediately life-threatening. Choice B, a diabetic client with an infected sore on the foot, requires timely care to prevent complications but can generally wait for evaluation compared to the potential urgency of adrenal insufficiency. Choice D, a client with a fracture of the forearm in an air splint, is important but not as time-sensitive as a client potentially in shock.
The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the physician?
- A. "I had chickenpox when I was 8 years old."?
- B. "I had rheumatic fever when I was 10 years old."?
- C. "I have a strong family history of gastric cancer."?
- D. "I have pain in my hip with any movement."?
Correct Answer: B
Rationale: The most important statement for the nurse to report to the physician is that the client had rheumatic fever when they were 10 years old. This information is crucial as individuals who have had rheumatic fever require pre-medication with antibiotics before any surgical or dental procedure to prevent bacterial endocarditis. Reporting this history ensures the client's safety during the hip replacement surgery. The other options, such as having chickenpox in the past, a family history of gastric cancer, or experiencing hip pain, are important for the client's overall health assessment but do not have the same immediate implications for the upcoming surgery as the history of rheumatic fever.
While making rounds at 3 am, the nurse discovers a small fire in a client's room. What should the nurse do first?
- A. Remove the client from the room immediately.
- B. Leave the client's room to obtain a fire extinguisher.
- C. Instruct a nurse tech to pull the fire alarm.
- D. Evacuate all clients from the unit.
Correct Answer: A
Rationale: During a fire emergency, the priority is the safety of the individual in the room where the fire is located. Removing the client from the room immediately is the first step in the RACE acronym for fire safety: Rescue/Remove, Alarm, Contain, and Extinguish. This action ensures the client's safety before addressing the fire itself. Choice B is incorrect as leaving the client's room to obtain a fire extinguisher can delay the immediate removal of the client from the danger. Choice C is incorrect as pulling the fire alarm should be done after ensuring the client's safety. Choice D is incorrect as evacuating all clients from the unit should come after ensuring the safety of the individual in immediate danger.