Nokea
The nurse is caring for a 10-year-old child on the pediatric unit. The nurse, when caring for this age group, should be aware that:
- A. The child will do something for another person if that person does something for the child.
- B. The child now follows social standards for the good of all.
- C. The child wants to follow the rules because of a need to be seen as 'good.'
- D. The child finds satisfaction in following rules.
Correct Answer: C
Rationale: 10-year-olds are in Kohlberg’s conventional stage, seeking approval by following rules to be seen as 'good.' Reciprocity, societal good, or intrinsic satisfaction are less applicable.
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The emergency department (ED) nurse is caring for a client with a head injury following a car accident. After a hyphema has been noted, the nurse should position the client
- A. Supine.
- B. Semi-Fowler's.
- C. Lateral on the affected side.
- D. Lateral on the unaffected side.
Correct Answer: B
Rationale: Semi-Fowler’s position (30-45 degrees) reduces intraocular pressure in hyphema, preventing complications. Supine or lateral positions may increase pressure.
The nurse observes a fire in a client's room. The nurse should take which initial action?
- A. Rescue the client
- B. Extinguish the fire
- C. Activate the fire alarm
- D. Place a linen blanket over the fire
Correct Answer: A
Rationale: Per the RACE protocol, rescuing the client is the initial action to ensure safety.
A health care provider (HCP) orders the immediate use of a piece of electrical care equipment for a client. When the nurse goes to use the piece of equipment, the nurse immediately suspects it may be faulty. The nurse should take which initial action?
- A. Try the piece of electrical care equipment and see if it becomes hazardous.
- B. Call the health care provider and report your suspicion.
- C. Ask the client if they want you to try the piece of electrical care equipment.
- D. Immediately remove the piece of electrical care equipment from service.
Correct Answer: D
Rationale: Removing faulty equipment from service prevents harm, the priority action. Trying it, consulting the client, or calling the provider delays safety measures.
The nurse supervises a student nurse preparing a client for a magnetic resonance imaging (MRI) test. Which of the following actions by the student nurse would require follow-up by the nurse? The student
- A. Asks the client if they have claustrophobia.
- B. Instructs the client to apply earplugs before the exam.
- C. Moves the nitroglycerin patch from the torso to the back.
- D. Tells the client that they will not have any exposure to radiation.
Correct Answer: C
Rationale: Moving a nitroglycerin patch can disrupt medication delivery and is unnecessary for MRI. Asking about claustrophobia, using earplugs, and confirming no radiation exposure are correct.
The nurse cares for a client scheduled for spinal surgery in one hour. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe
- A. gentamicin
- B. enoxaparin
- C. hydromorphone
- D. cyclobenzaprine
Correct Answer: B
Rationale: Enoxaparin, a low-molecular-weight heparin, is commonly prescribed preoperatively for spinal surgery to prevent venous thromboembolism due to prolonged immobility. Gentamicin is an antibiotic, hydromorphone is for pain, and cyclobenzaprine is a muscle relaxant, none of which are typically prioritized preoperatively for this purpose.