Nokea
The nurse is assisting at a disaster shelter setup following a devastating earthquake. What is the most common problem the nurse is likely to see in those who come to the shelter?
- A. Thirst
- B. Traumatic injuries
- C. Stress
- D. Exacerbation of medical problems
Correct Answer: C
Rationale: Stress is the most common issue post-disaster due to trauma and displacement, affecting most survivors. Thirst, injuries, or medical exacerbations are less universal.
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The nurse is collecting data from a client with a history of alcohol use disorder who had an emergency appendectomy 3 days ago. Which of the following findings would indicate that the client is experiencing delirium tremens? Select all that apply.
- A. Bradypnea
- B. Diaphoresis
- C. Hallucinations
- D. Lethargy
- E. Tachycardia
Correct Answer: B,C,E
Rationale: Delirium tremens presents with diaphoresis, hallucinations, and tachycardia due to autonomic hyperactivity. Bradypnea and lethargy are not typical; agitation is more common.
The nurse is acting as a preceptor for a student nurse in the labor and delivery unit. Which action by the student would require correction by the nurse?
- A. Removing gloves prior to removing isolation gown
- B. Using a nail brush to scrub underneath artificial nails
- C. Using alcohol-based hand sanitizer instead of washing hands when entering and exiting client room
- D. Washing hands and not wearing gloves when preparing medications in the med room
Correct Answer: B
Rationale: Artificial nails harbor bacteria, and scrubbing underneath is inadequate; they should be avoided in labor and delivery. Other actions align with infection control protocols.
Which of these clients would be most appropriate to assign to a practical nurse (PN)?
- A. A trauma victim with quadriplegia and a client 1 day post-op radical neck dissection
- B. A client with newly diagnosed type 2 diabetes mellitus and a client with a history of AIDS admitted for pneumonia
- C. A client with hemiplegia is fed by a nasogastric tube and client with a left leg amputation in rehabilitation
- D. A client with a history of schizophrenia in alcohol withdrawal and a client with chronic renal failure
Correct Answer: C
Rationale: This client requires supportive care and interventions within the scope of practice of a PN. This client is stable with little risk of complications or instability.
The nurse is discussing activities to promote language development with the parent of a 2-year-old. Which statement by the parent requires follow-up?
- A. I have dress-up clothes set out for my child to play with.
- B. I read brightly-colored picture books with rhymes with my child
- C. I set out a basket of toy cars when other children come to play
- D. I will enroll my child to play on a soccer team
Correct Answer: D
Rationale: Enrolling a 2-year-old in soccer is premature, as it does not directly promote language development and is not age-appropriate. Reading rhyming books and facilitating peer play with toys support language skills.
The nurse in the outpatient care facility is caring for a client with metastatic lung cancer who received chemotherapy 3 days ago. The client states, 'I have decided that I do not want to continue treatment.' Which of the following responses would be appropriate for the nurse to make?
- A. That is not an easy choice to make. I will notify your health care provider of your decision
- B. Have you considered how this decision might affect your spouse and children?
- C. I do not think it is wise to stop chemotherapy. You will become too sick to enjoy your life
- D. Have you discussed this decision with someone else that you trust?
Correct Answer: A
Rationale: Acknowledging the decision’s difficulty and notifying the provider respects autonomy and ensures follow-up. Other responses judge, guilt, or deflect the client’s choice.