Nokea
The nurse enters a client's room who is found on the ground. The nurse should perform which initial action?
- A. Assess the client's level of consciousness
- B. Examine the client for injuries
- C. Call the rapid response team (RRT)
- D. Palpate the client's carotid pulse
Correct Answer: A
Rationale: Assessing the level of consciousness is the initial action to determine the client's neurological status and guide further interventions after a fall.
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The nurse is applying a prescribed cold compress to the client's sprained ankle and recognizes that it should be applied for a maximum of
- A. 20 minutes.
- B. 10 minutes.
- C. 30 minutes.
- D. 15 minutes.
Correct Answer: A
Rationale: Cold compresses should be applied for 20 minutes to prevent tissue damage while reducing swelling. Shorter or longer durations are less effective or risky.
The nurse is caring for a client immediately postoperative following a below-the-knee amputation. The nurse should take which priority action?
- A. Elevate the stump on a pillow
- B. Check the operative site for bleeding
- C. Obtain an order for a physical therapy order
- D. Demonstrate the use of incentive spirometry (IS)
Correct Answer: B
Rationale: Checking the operative site for bleeding is the priority to detect hemorrhage, a life-threatening complication in the immediate postoperative period. Elevating the stump may be contraindicated to prevent contractures, physical therapy orders are not immediate, and incentive spirometry, while important, is secondary to hemorrhage control.
The nurse is part of an infection control committee that is responding to an outbreak of norovirus in the long-term care facility. Which recommendation should the nurse make to prevent further transmission of this outbreak?
- A. Place face shields outside client rooms.
- B. Discontinue indwelling urinary catheters that are not medically necessary.
- C. Wipe down surfaces with hot, soapy water.
- D. Increase the frequency of cleaning and disinfection of client care areas.
Correct Answer: D
Rationale: Increased cleaning and disinfection of surfaces prevent norovirus spread via contaminated surfaces. Face shields, catheter discontinuation, and soapy water are less effective.
Your client is reluctant to take a necessary dose of narcotic analgesic for severe pain. The client states, 'I do not want to become a druggie.' How would you respond to this client's comment?
- A. That is ridiculous. Nobody gets addicted to narcotics when they do not have a prior history of drug abuse.
- B. The possible complications of unrelieved pain greatly outweigh the risk of addiction which is very low when a person has no prior history of drug abuse.
- C. A lot of people prefer to be brave and stick it out so you are not alone.
- D. You have a right to refuse any and all treatments, so just do without it.
Correct Answer: B
Rationale: Addressing pain complications and reassuring low addiction risk educates and encourages treatment. Dismissing concerns, normalizing endurance, or supporting refusal are non-therapeutic.
The nurse is caring for a client who has nausea related to prescribed chemotherapy treatments. The nurse should recommend that the client. Select all that apply.
- A. Consume foods and liquids at room temperature.
- B. Drink a large amount of fluid with meals.
- C. Consume foods without aromas
- D. Eat smaller portion sizes throughout the day.
- E. Delay taking the prescribed antiemetic until the nausea is severe.
Correct Answer: A,C,D
Rationale: Room-temperature foods, low-aroma foods, and smaller portions reduce nausea. Large fluid intake with meals worsens nausea, and antiemetics should be taken proactively.