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The nurse in the emergency department is caring for a client who sustained blunt force head trauma and is experiencing blurry vision. The nurse should suspect the client has sustained injury to the
- A. temporal lobe
- B. occipital lobe
- C. parietal lobe
- D. frontal lobe
Correct Answer: B
Rationale: Blurry vision post-head trauma suggests injury to the occipital lobe , which processes visual information. Temporal , parietal , and frontal lobes manage other functions.
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When walking past a client's room, the nurse hears 1 unlicensed assistive personnel (UAP) talking to another UAP. Which statement requires follow-up intervention?
- A. If we work together we can get all of the client care completed.
- B. Since I am late for lunch, would you do this one client's glucose test?
- C. If we client seems confused, we need to watch another closely.
- D. I'll come back and make the bed after I go to the lab.
Correct Answer: B
Rationale: Only the RN and PN can delegate to UAPs. One UAP cannot delegate a task to another UAP. The RN or PN is legally accountable for the nursing care.
The nurse is collecting data from a client who delivered a full-term newborn vaginally 12 hours ago after prolonged labor. Which of the following findings would be essential to follow up?
- A. foul-smelling lochia
- B. external hemorrhoids
- C. temperature of 100 F (37.8 C)
- D. discomfort during fundal massage
Correct Answer: A
Rationale: Foul-smelling lochia suggests possible endometritis or infection, requiring immediate follow-up. External hemorrhoids and mild temperature elevation are common postpartum findings, and discomfort during fundal massage is expected unless accompanied by other concerning signs.
A client with Cushing's syndrome should be instructed to:
- A. Avoid alcoholic beverages
- B. Limit the sodium in her diet
- C. Increase servings of dark green vegetables
- D. Limit the amount of protein in her diet
Correct Answer: B
Rationale: A client with Cushing's syndrome has adrenocortical hypersecretion, so she retains sodium and water. The client may drink alcohol in moderation, so answer A is incorrect, and there is no need to eat more green vegetables or limit protein, so answers C and D are incorrect.
The nurse in the emergency department is caring for a client who was involved in a motor vehicle collision. Which of the following diagnostic test results would best determine the client's oxygenation and ventilation status?
- A. peak expiratory flow rate reading
- B. arterial blood gas analysis
- C. pulse oximetry reading
- D. CT scan of the chest
Correct Answer: B
Rationale: Arterial blood gas provides the most accurate assessment of oxygenation (PaO2) and ventilation (PaCO2) post-collision. Peak flow assesses asthma, pulse oximetry measures oxygen saturation only, and CT evaluates structure.
Laboratory Reference Range
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L)
The nurse has received information from unlicensed assistive personnel about assigned client situations. Which of the following situations should the nurse address first?
- A. Client who has type 1 diabetes mellitus and a fasting capillary blood glucose level of 90 mg/dL (5.0 mmol/L)
- B. client who is collecting a 24-hour urine specimen and discarded the last void by mistake
- C. client who is requesting clarification about the diagnostic procedure that is scheduled to begin in 4 hours
- D. client who was recently admitted to a room that has a full sharps disposal container on the wall
Correct Answer: D
Rationale: A full sharps container poses an immediate safety hazard and must be addressed first. Normal glucose , a discarded void , and procedure clarification are less urgent.