Nokea
The nurse enters the room of a 5-year-old client and finds the client lying on the floor. The fall was unwitnessed. What is the priority nursing action?
- A. File an incident report
- B. Assist the child back to bed
- C. Call for help
- D. Assess the child for any injuries
Correct Answer: D
Rationale: Assessing the child for injuries (D) is the priority to identify potential harm, such as head trauma. Calling for help (C), assisting back to bed (B), and filing a report (A) follow after ensuring the child’s safety.
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The nurse preceptor is observing a newly hired nurse care for assigned clients. It would require follow-up by the nurse preceptor if the newly hired nurse is observed doing which of the following?
- A. Humidifies nasal cannula oxygen for a client with sarcoidosis.
- B. Secures a suprapubic catheter tubing to a client’s inner thigh.
- C. Places a client with varicella-zoster in airborne and contact isolation.
- D. Suctions a tracheostomy for 10 seconds as they remove the catheter.
Correct Answer: D
Rationale: Suctioning a tracheostomy for 10 seconds (D) risks hypoxia and trauma, requiring follow-up as it should be brief (5-10 seconds max). Humidifying oxygen (A), securing catheters (B), and isolating varicella (C) are correct practices.
The nurse is caring for assigned clients with newly received prescriptions. Which prescription should the nurse administer first? See the exhibit.
- A. Levofloxacin 750 mg IVPB Q12 hours
- B. 0.9% Saline 125 ml/hr
- C. Metoclopramide 10 mg IV Push Q8 hours
- D. Ketorolac 15 mg IV Push Q8 hours
Correct Answer: A
Rationale: Pneumonia in an elderly client can be particularly severe due to age-related immune system decline and potential for complications like acute respiratory distress syndrome (ARDS) and/or sepsis.
The nurse working on a medical-surgical unit is caring for assigned clients. The nurse should plan to initially assess the client who
- A. had a subtotal thyroidectomy 12 hours ago and reports difficulty swallowing.
- B. reports increased pain following a sterile dressing change for a stage IV pressure ulcer.
- C. has bilateral lower lobe pneumonia and has not used the incentive spirometer in six hours.
- D. is scheduled for an adrenalectomy in eight hours and has not signed the informed consent.
Correct Answer: A
Rationale: Difficulty swallowing post-thyroidectomy (A suggests complications like hematoma or nerve injury, which can be life-threatening and require immediate assessment. Increased pain (B), and not using an incentive spirometer (C), and lack of consent (D) are less urgent and critical.
A client has just been diagnosed with a terminal illness. She decides to execute a living will in the unit and asks the nurse to be the witness of the will. What is the most appropriate response by the nurse?
- A. I'm sorry, but under the law, we're not allowed to witness living wills.'
- B. Let me call the doctor. Maybe he can witness it for you.'
- C. Your family are the only people that can serve as witnesses.'
- D. Let me call the hospital attorney; he needs to be present when you sign your will.'
Correct Answer: A
Rationale: In many jurisdictions, nurses are restricted from witnessing living wills (A) due to potential conflicts of interest. Doctors (B) or attorneys (D) are not required, and family-only witnesses (C) is incorrect, as non-family can witness.
The nurse is caring for assigned clients. The nurse should prioritize seeing the client who
- A. has a chest tube attached to a closed-chest drainage system to treat a pneumothorax and reports increased dyspnea and dizziness.
- B. is being treated for acute pancreatitis and reports nausea and pain rated 6 on a scale of 0 (no pain) to 10 (severe pain).
- C. is being treated for pheochromocytoma and reports a headache, and most recent blood pressure is 149/84 mm Hg.
- D. has pneumonia with atelectasis and has had decreased breath sounds in the affected lobe.
Correct Answer: A
Rationale: Dyspnea and dizziness with a chest tube for pneumothorax (A) suggest complications like tube malfunction or hemothorax, requiring immediate assessment. Pancreatitis pain (B), headache with pheochromocytoma (C), and decreased breath sounds in pneumonia (D) are less urgent.