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The nurse in the emergency department is responsible for the triage of four recently admitted clients. Which client should the nurse send directly to the treatment room?
- A. A 23-year-old female complaining of headache and nausea
- B. A 76-year-old male complaining of dysuria
- C. A 56-year-old male complaining of exertional shortness of breath
- D. A 42-year-old female complaining of recent sexual assault
Correct Answer: C
Rationale: Exertional shortness of breath may indicate a cardiac or respiratory emergency, requiring immediate attention.
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A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:
- A. Decreased blood pressure and constricted pupils
- B. Increased heart rate and increased respirations
- C. Increased respirations and increased blood pressure
- D. Anoxia and absence of the cough reflex
Correct Answer: A
Rationale: Cholinergic crisis, due to excessive acetylcholinesterase inhibitors, causes symptoms like constricted pupils and decreased blood pressure from parasympathetic overstimulation.
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 client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?
- A. Macaroni and cheese
- B. Shrimp with rice
- C. Turkey breast
- D. Spaghetti with meat sauce
Correct Answer: C
Rationale: Turkey breast is lean and has the lowest saturated fat content compared to the other options, which contain higher-fat ingredients.
The nurse is obtaining a history on an 80-year-old client. Which statement made by the client might indicate a potential for fluid and electrolyte imbalance?
- A. My skin is always so dry.
- B. I often use laxatives.
- C. I have always liked to drink a lot of ice tea.
- D. I sometimes have a problem with dribbling urine.
Correct Answer: B
Rationale: Frequent laxative use can lead to dehydration and electrolyte imbalances due to excessive fluid and electrolyte loss through diarrhea.
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.