Nokea
The nurse is attending an end-of-year school family picnic. Which situation needs an immediate intervention?
- A. A 2-year-old eating a hot dog unsupervised
- B. A 3-year-old playing alone in a wading pool
- C. A 4-year-old tossing a beach ball
- D. A 5-year-old climbing on monkey bars
Correct Answer: B
Rationale: A 3-year-old alone in a wading pool is at immediate risk of drowning, requiring urgent intervention. A poses a choking risk but is less immediately life-threatening. C and D are age-appropriate activities with lower immediate risk.
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The nurse is obligated to make a report for which situations? Select all that apply.
- A. Report to a client's employer that the client had a car crash while intoxicated
- B. Report to the authorities of a death by suicide on the unit
- C. Report to the client's spouse that the client has a reportable sexually transmitted disease
- D. Report to the hotline that an elderly client has suspicious bruising but denies caregiver abuse
- E. Report to the supervisor that a health care provider has the smell of alcohol on the breath
Correct Answer: B,D,E
Rationale: Reporting is mandatory for suicides, suspected elder abuse, and impaired providers. Reporting to employers or spouses violates confidentiality.
The oncoming nurse is receiving report on 4 clients. Which should be the priority assessment?
- A. Client who had a carotid endarterectomy that day with a blood pressure of 160/88 mm Hg
- B. Client who is 1 day post bowel resection with absent bowel sounds
- C. Client with a pulse of 109/min who has a history of atrial fibrillation
- D. Client with pancreatitis whose total parenteral nutrition is almost finished
Correct Answer: A
Rationale: Elevated blood pressure (160/88 mm Hg) post-carotid endarterectomy risks hematoma or stroke, making it the priority. Other conditions are less urgent.
A client 4 days post colostomy is preparing to be discharged home. Which findings are concerning and should be further investigated? Select all that apply.
- A. Client states, 'I will need home health to empty the pouch.'
- B. Client states, 'There is a little gas in the colostomy bag.'
- C. No bowel sounds are present and the client reports nausea
- D. Skin surrounding the stoma is red and excoriated
- E. Stoma is red, edematous, and smaller than the previous day
Correct Answer: C,D,E
Rationale: Absent bowel sounds with nausea suggest obstruction, red/excoriated skin indicates irritation, and a shrinking stoma may signal complications. Gas is normal, and needing home health is not inherently concerning.
A client with seizure disorder has an order for Dilantin (Phenytoin). Which of the following is not a side effect of Dilantin (Phenytoin)?
- A. Gingival hypertrophy
- B. Insomnia
- C. Diarrhea
- D. Slurred speech
Correct Answer: B
Rationale: Dilantin causes gingival hypertrophy, slurred speech, and occasionally diarrhea, but insomnia is not a common side effect.
The nurse in the outpatient clinic is talking with a client who sustained a distal fracture of the humerus and had a cast applied 2 days ago. Which of the following statements by the client would be a priority to follow up?
- A. I am able to insert one finger between my cast and arm.
- B. I use a nail file to scratch my skin under the cast when it itches.
- C. I am having difficulty extending my fingers since I woke up this morning.
- D. I cannot take the prescribed pain medication because it makes me nauseous.
Correct Answer: C
Rationale: Difficulty extending fingers suggests nerve compression or compartment syndrome, a priority for follow-up. Other statements are less urgent.