Nokea
The nurse in the ER has received report of four clients en route to the emergency department. Which client should the nurse see first? A client with:
- A. Third-degree burns to the face and neck area, with singed nasal hairs
- B. Second-degree burns to each leg and thigh area, who is alert and oriented
- C. A chemical burn that has been removed and liberally flushed before admission
- D. An electrical burn entering and leaving on the same side of the body
Correct Answer: A
Rationale: Third-degree burns to the face and neck with singed nasal hairs suggest airway burns, a life-threatening condition requiring immediate airway assessment and management.
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Following a disaster with multiple victims and danger to those present, which group should have priority for protection from injury?
- A. The clients/victims.
- B. The firefighters and police officers.
- C. The bystanders and news reporters.
- D. The healthcare providers.
Correct Answer: B
Rationale: Firefighters and police officers (B) have priority for protection as they are essential for managing the disaster and ensuring safety for others. Victims (A), bystanders (C), and healthcare providers (D) follow in priority.
A 52-year-old client is undergoing menopause. Which of the following physical sign or symptom is often attributed to decreased estrogen production associated with menopause?
- A. Weight loss
- B. Excessive sleeping
- C. Increased fat deposits on hips and abdomen
- D. Increased metabolic rate
Correct Answer: C
Rationale: Decreased estrogen in menopause often leads to increased fat deposits on hips and abdomen (C). Weight loss (A), excessive sleeping (B), and increased metabolic rate (D) are not typical.
Four days after delivery, a client develops complications of postpartal hemorrhage. The most common cause of late postpartal hemorrhage is:
- A. Uterine atony
- B. Retained placental fragments
- C. Cervical laceration
- D. Perineal tears
Correct Answer: B
Rationale: Retained placental fragments are the most common cause of late postpartum hemorrhage, as they prevent proper uterine contraction and hemostasis.
To maintain Bryant's traction, the nurse must make certain that the child's:
- A. Hips are resting on the bed, with the legs suspended at a right angle to the bed
- B. Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed
- C. Hips are elevated above the level of the body on a pillow and the legs are suspended parallel to the bed
- D. Hips and legs are flat on the bed, with the traction positioned at the foot of the bed
Correct Answer: B
Rationale: Bryant's traction requires hips slightly elevated and legs at a right angle to the bed to maintain alignment and traction.
A 6-month-old is hospitalized with symptoms of botulism. What aspect of the infant's history is associated with Clostridium botulinum infection?
- A. The infant sucks on his fingers and toes.
- B. The mother sweetens the infant's cereal with honey.
- C. The infant was switched to soy-based formula.
- D. The father recently purchased an aquarium.
Correct Answer: B
Rationale: Honey can contain Clostridium botulinum spores, which are a common cause of infant botulism in children under 12 months, as their digestive systems cannot eliminate the spores.