Nokea
The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should:
- A. Apply a clean dressing to protect the wound
- B. Cover the exposed viscera with a sterile saline gauze
- C. Gently replace the abdominal contents
- D. Cover the area with a petroleum gauze
Correct Answer: B
Rationale: Covering exposed viscera with sterile saline gauze keeps the tissue moist and prevents infection until surgical intervention, as replacing contents or using non-sterile dressings risks contamination.
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The nurse is caring for a child in a plaster-of-Paris hip spica cast. To facilitate drying, the nurse should:
- A. Use a small hand-held hair dryer set on medium heat
- B. Place a small heater near the child's bed
- C. Turn the child at least every 2 hours
- D. Allow one side to dry before changing positions
Correct Answer: C
Rationale: Turning the child every 2 hours ensures even drying of the cast and prevents pressure sores, promoting comfort and healing.
Which of the following are common neurological changes associated with aging? Select all that apply.
- A. Dementia occurs.
- B. Threshold for sensory input increases.
- C. Perspiration is reduced.
- D. Short-term memory is impaired.
- E. Muscles atrophy.
Correct Answer: B,D
Rationale: Aging commonly increases sensory input threshold (B), making stimuli harder to perceive, and impairs short-term memory (D). Dementia (A) is not universal, perspiration reduction (C) is not neurological, and muscle atrophy (E) is musculoskeletal.
The priority nursing intervention for a client with sickle cell crisis is to
- A. administer pain medication.
- B. administer packed RBC.
- C. administer oxygen.
- D. administer IV fluids.
Correct Answer: D
Rationale: IV fluids are the priority in sickle cell crisis to reduce blood viscosity, promote perfusion, and prevent organ damage.
The nurse is making a home visit to an elderly client during the summer. Upon arrival, the nurse notices the refrigerator and freezer doors are open as the client is using both for air conditioning. Which of the following actions by the nurse are most appropriate?
- A. instruct the client to place a fan in front of the freezer to enhance circulation of cool air
- B. hold a meeting with the client and family to advise them of the safety risks of this practice
- C. note this observation in the client's medical record, but do not discuss with the client
- D. report the incident to the nursing supervisor
Correct Answer: B
Rationale: Discussing the risks (e.g., food spoilage, electrical hazards) with the client and family promotes safety and education.
The nurse is caring for a client following the removal of a central line catheter when the client suddenly develops dyspnea and complains of substernal chest pain. The client is noticeably confused and fearful. Based on the client's symptoms, the nurse should suspect which complication of central line use?
- A. Myocardial infarction
- B. Air embolus
- C. Intrathoracic bleeding
- D. Vagal response
Correct Answer: B
Rationale: Sudden dyspnea, chest pain, and confusion post-central line removal suggest an air embolus, a serious complication requiring immediate intervention.