Nokea
The nurse enters a client's room and finds him lying on the floor. The client says to the nurse, 'I fell because I was trying to go to the bathroom and no one answered my call light.' Which of the following actions by the nurse are correct? Select all that apply.
- A. assist the client back to bed
- B. complete an incident report
- C. notify the health care provider
- D. assess the client for any injuries
- E. document in the medical record that the client fell
Correct Answer: A,B,C,D,E
Rationale: All actions are appropriate: assist the client safely, assess for injuries, notify the provider, complete an incident report, and document the fall to ensure proper care and follow-up.
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The nurse is teaching circumcision care to the mother of a newborn. Which statement indicates that the mother needs further teaching?
- A. I will apply a petroleum gauze to the area with each diaper change.
- B. I will clean the area carefully with each diaper change.
- C. I can place a heat lamp to the area to speed up the healing process.
- D. I should carefully observe the area for signs of infection.
Correct Answer: C
Rationale: Using a heat lamp is incorrect and could cause burns or delay healing; the other statements reflect appropriate circumcision care.
The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40. The initial nurse's action should be to:
- A. Place the client in Trendelenburg position
- B. Increase the infusion of normal saline
- C. Administer atropine intravenously
- D. Move the emergency cart to the bedside
Correct Answer: B
Rationale: Hypotension and unresponsiveness suggest hypovolemia or shock, so increasing the normal saline infusion is the initial action to restore volume.
Which person is at greatest risk for developing Lyme's disease?
- A. Computer programmer
- B. Elementary teacher
- C. Veterinarian
- D. Landscaper
Correct Answer: D
Rationale: Landscapers are at higher risk for Lyme disease due to frequent exposure to tick-infested outdoor environments, where the disease is transmitted.
The nurse is caring for a postcholecystectomy client who had the T-tube removed this AM. Two hours after removal of the T-tube, the nurse notes that the 4x4 dressing covering the stab site is saturated with dark, greenish-yellow drainage. It is MOST appropriate for the nurse to take which of the following actions?
- A. Remove the dressing and replace it with a more absorbent dressing.
- B. Collect a culture and sensitivity specimen of the drainage.
- C. Observe the wound for dehiscence.
- D. Reinforce the dressing with an 8x10 dressing.
Correct Answer: A
Rationale: expected that a stab wound will continue to drain until the wound seals; nurse should keep wound clean and dry
The primary cause of anemia in a client with chronic renal failure is:
- A. Poor iron absorption
- B. Destruction of red blood cells
- C. Lack of intrinsic factor
- D. Insufficient erythropoietin
Correct Answer: D
Rationale: Chronic renal failure reduces erythropoietin production by the kidneys, leading to decreased red blood cell production and anemia.