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The nurse arrives at a motorcycle accident and finds the client unresponsive, apneic, and pulseless. After calling for a spectator to help, what would be the nurse's next action?
- A. Ventilate with a mouth-to-mask device
- B. Begin chest compressions
- C. Administer a precordial thump
- D. Open the airway
Correct Answer: B
Rationale: Per ACLS guidelines, for an unresponsive, apneic, pulseless client, start chest compressions immediately after calling for help to restore circulation.
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The nurse is caring for a client after an open reduction to the left ulna. The client's left arm is in a plaster cast with an Ace wrap for reinforcement. Which intervention by the nurse can offer nonpharmacological comfort to this client?
- A. elevate the left arm on a pillow and apply an ice pack over the approximate location of the surgical incision
- B. call the physician and obtain an order for acetaminophen (Tylenol) 650 mg PO PRN q6 hours as needed for pain
- C. advise the client that if he starts to itch under the cast, he can use a wire coat hanger or an ink pen to gently scratch up under the cast
- D. perform range-of-motion exercises twice a shift, including bending the fingers, opening and closing the hand, and lifting the arm up to shoulder level
Correct Answer: A
Rationale: Elevation and ice reduce swelling and pain nonpharmacologically. Scratching under the cast risks skin damage, and excessive movement may disrupt healing.
A school nurse is approached by a student who says that her friend has been cutting herself on the arms. The student asks the nurse not to tell anyone. Which response by the nurse is correct?
- A. I have to notify her parents, because this affects her personal safety.
- B. I won't tell anyone, but let me know if she starts talking about suicide.
- C. I will call the hospital and let them send a psychiatrist to do an evaluation on your friend.
- D. I will make it a point to run into her in the hall and notice the cuts on her arms so I can ask about them.
Correct Answer: A
Rationale: Self-harm indicates a safety risk, requiring parental notification to ensure the student receives appropriate intervention.
A client is provided instructions for a low-sodium diet. Which statement by the client indicates an understanding of the diet?
- A. I'll miss eating tomatoes.
- B. I'll enjoy eating take-out more frequently.
- C. I'll avoid potato chips and cheese.
- D. I'll miss eating celery.
Correct Answer: C
Rationale: Potato chips and cheese are high-sodium foods, and avoiding them shows understanding of a low-sodium diet. Tomatoes and celery are low-sodium, and take-out is often high-sodium.
The physician has ordered a low-purine diet for a client with gout. Which protein source is high in purine?
- A. Dried beans
- B. Nuts
- C. Cheese
- D. Eggs
Correct Answer: A
Rationale: Dried beans are high in purines, which can increase uric acid levels and exacerbate gout symptoms.
Nurses must be familiar with the American Nurses Association (ANA) Code of Ethics for Nurses. The nurse understands that which ethical principle is defined as the nurse's duty to do no harm? Fill in the blank.
- A. Nonmaleficence
- B. Bneficence
- C. autonomy
Correct Answer: A
Rationale: Nonmaleficence is the ethical principle of doing no harm, a core duty in nursing practice.