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The nurse is assisting with the care of a client who sustained a cervical spinal cord injury 1 hour ago and has paralysis in all four extremities. Which of the following actions would be a priority for the nurse to take?
- A. Reposition the client every 2 hours.
- B. Monitor the client for autonomic dysreflexia.
- C. Check the client's respiratory status frequently
- D. Perform passive range-of-motion exercises every 4 hours.
Correct Answer: C
Rationale: Respiratory status (C) is the priority in acute cervical spinal cord injury due to risk of respiratory failure. Repositioning (A), dysreflexia monitoring (B), and exercises (D) are secondary.
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The nurse is teaching a client with cardiac disease about the anatomy and physiology of the heart. Which is the correct pathway of blood flow through the heart?
- A. Right ventricle, left ventricle, right atrium, left atrium
- B. Left ventricle, right ventricle, left atrium, right atrium
- C. Right atrium, right ventricle, left atrium, left ventricle
- D. Right atrium, left atrium, right ventricle, left ventricle
Correct Answer: C
Rationale: Right atrium, right ventricle, left atrium, left ventricle. This is the correct pathway of blood flow through the heart.
A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning?
- A. Use ready-to-feed commercial infant formula
- B. Boil the tap water for 10 minutes prior to preparing the formula
- C. Let tap water run for 2 minutes before adding to concentrate
- D. Buy bottled water labeled 'lead free' to mix the formula
Correct Answer: C
Rationale: Use of lead-contaminated water to prepare formula is a major source of poisoning in infants. Letting tap water run for several minutes will diminish the lead contamination.
The nurse is caring for a newly admitted man who has kidney stones. The man asks if he can get up and take a walk. How should the nurse respond?
- A. It is better for you to remain in bed until the stones pass.'
- B. Stay in bed until I check with your physician.'
- C. Walking is good for you. Let me help you up.'
- D. It is safe for you to ambulate once a day.'
Correct Answer: C
Rationale: Walking may facilitate kidney stone passage and is generally safe unless contraindicated, with assistance ensuring safety.
The charge nurse in a long-term care facility is making assignments. When assigning personnel to care for residents, which principle is important?
- A. Assignments should be rotated on a daily basis.
- B. Clients who are confused often do better with the same caregiver for several days.
- C. Female caregivers should not care for male residents.
- D. Caregivers should be allowed to select the residents they will care for.
Correct Answer: B
Rationale: Consistency with caregivers reduces anxiety and improves trust for confused clients, enhancing care quality. Daily rotation, gender restrictions, or caregiver choice are less effective.
The nurse is caring for assigned clients. The nurse should first check the client with
- A. liver cirrhosis who has a decreased RBC count and is reporting pruritis
- B. pneumonia who has an elevated WBC count and coarse crackles bilaterally
- C. atrial fibrillation who has an irregular heart rate of 122/min and is reporting palpitations
- D. pericarditis who has muffled heart sounds and a decrease in systolic blood pressure of 20 mm Hg with inspiration
Correct Answer: D
Rationale: Pericarditis with paradoxical pulse (D) suggests tamponade, requiring immediate assessment. Atrial fibrillation (C), pneumonia (B), and cirrhosis (A) are less urgent.