Nokea
The nurse is assessing the nursing care unit in a long-term facility for fire hazards. Which finding is the greatest fire hazard?
- A. Some of the nurses and nursing assistants smoke in the restroom.
- B. There are several cardboard boxes and cleaning supplies stored in the room with the emergency oxygen supply.
- C. Several residents have dust under their beds.
- D. Two of the residents have closets that are stuffed full of photo albums and sewing supplies.
Correct Answer: B
Rationale: Storing flammable materials near oxygen increases fire risk, as oxygen supports combustion. Smoking, dust, or cluttered closets are less hazardous.
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Promethazine hydrochloride (Phenergan) 25 mg IV push has been ordered for a patient. Before administering this medication to the patient, the nurse should check the
- A. color of the medication solution.
- B. patient's pulse and temperature.
- C. time of the last analgesic dose the patient received.
- D. patency of the patient's vein.
Correct Answer: D
Rationale: is very important to determine absolute patency of the vein; extravasation will cause necrosis
The nurse is providing home care. Which assessment finding would suggest to the nurse that the elderly client should be evaluated for abuse?
- A. The client says, 'My daughter takes some of my Social Security money. She says it's to pay for my food and medicine.'
- B. The client has several bruises on her arms and legs.
- C. The client says her family is mean because they hire someone to stay with her when they go out.
- D. The client has several bruises and circular marks that look like cigarette burns on her back.
Correct Answer: D
Rationale: Bruises and circular marks resembling cigarette burns strongly suggest physical abuse, requiring immediate evaluation. Unexplained bruises are concerning but less specific, and the other options may reflect misunderstanding or caregiving arrangements.
The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB?
- A. Tuberculin skin testing
- B. Sputum culture
- C. White blood cell count
- D. Chest x-ray
Correct Answer: B
Rationale: Sputum culture. The sputum culture is the most accurate method for determining the presence of active TB.
An 11-year-old boy with a minor head injury treated at the outpatient clinic.
The nurse determines that further teaching is necessary if the mother makes which of the following statements? dimensional visualization of the vertebral canal.'
- A. My son may have dizziness for 24 hours.'
- B. My son can drink carbonated beverages if he vomits.'
- C. My son may complain of nausea.'
- D. My son will probably have a headache.'
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to a minor head injury. (1) expected for at least 24 hours (2) correct-unexpected, should be reported to physician immediately, also unexpected is blurred vision, drainage from ear or nose, weakness, slurred speech, worsening headache (3) expected for at least 24 hours (4) expected for at least 24 hours, should not get more intense
The nurse is caring for a woman who is admitted following a beating by her husband. The woman says, 'It wasn't really his fault. Dinner was late.' The husband arrives to visit his wife with a large bouquet of flowers and a box of chocolates. The woman later says to the nurse, 'He feels so bad about what he did and says it will never happen again.' What concept should guide the nurse when replying to the client?
- A. Men who abuse their wives and then repent usually do not do it again.
- B. The woman is quite perceptive and should be safe when she is discharged.
- C. Abuse is often followed by repentance and then again by abuse.
- D. Spousal abuse is usually a result of misbehavior on the part of the abused.
Correct Answer: C
Rationale: The cycle of abuse often includes remorse followed by repeated abuse, guiding the nurse to educate about patterns, not assume safety or blame the victim.