Nokea
The nurse is caring for a 13-year-old in the pediatric unit with a left-side below-the-knee cast. The client reports pain and numbness in the foot. The nurse notes that the toes of the left foot are cold. Which of the following actions should the nurse take first?
- A. Remove the cast.
- B. Have the child ambulate.
- C. Notify the physician.
- D. Elevate the leg on two pillows.
Correct Answer: C
Rationale: Pain, numbness, and cold toes in a casted limb (C) suggest compartment syndrome, a medical emergency requiring immediate physician notification to prevent tissue damage. Removing the cast (A), ambulating (B), or elevating (D) without orders could worsen the condition.
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The nurse preceptor is observing a newly hired nurse care for assigned clients. It would require follow-up by the nurse preceptor if the newly hired nurse is observed doing which of the following?
- A. Humidifies nasal cannula oxygen for a client with sarcoidosis.
- B. Secures a suprapubic catheter tubing to a client’s inner thigh.
- C. Places a client with varicella-zoster in airborne and contact isolation.
- D. Suctions a tracheostomy for 10 seconds as they remove the catheter.
Correct Answer: D
Rationale: Suctioning a tracheostomy for 10 seconds (D) risks hypoxia and trauma, requiring follow-up as it should be brief (5-10 seconds max). Humidifying oxygen (A), securing catheters (B), and isolating varicella (C) are correct practices.
The nurse is reviewing their written documentation and notices an error. The nurse should correct the error by Select all that apply.
- A. drawing a line through the erroneous documentation.
- B. using correction tape and write over the error.
- C. writing over the error in darker ink.
- D. completely black out the error with a black marker.
- E. discarding the documentation in the trash and starting over.
- F. writing your initials, date, and time above the erroneous documentation with the word 'error.'
Correct Answer: A, F
Rationale: Correcting documentation errors involves drawing a single line through the error (A) and initialing, dating, and noting 'error' (F). Correction tape (B), writing over (C), blacking out (D), or discarding (E) are incorrect and violate documentation standards.
The nurse enters the room of a 5-year-old client and finds the client lying on the floor. The fall was unwitnessed. What is the priority nursing action?
- A. File an incident report
- B. Assist the child back to bed
- C. Call for help
- D. Assess the child for any injuries
Correct Answer: D
Rationale: Assessing the child for injuries (D) is the priority to identify potential harm, such as head trauma. Calling for help (C), assisting back to bed (B), and filing a report (A) follow after ensuring the child’s safety.
The nurse has received the following prescriptions for newly admitted clients. Which medication should the nurse administer first?
- A. Subcutaneous (SubQ) epoetin for anemia
- B. oxycodone by mouth (PO) for pain control
- C. Intravenous (IV) fluids for sepsis
- D. Intramuscular (IM) hydroxyzine for anxiety
Correct Answer: C
Rationale: IV fluids for sepsis (C) are the priority to restore perfusion and prevent organ failure. Epoetin (A) addresses chronic anemia, oxycodone (B) manages pain, and hydroxyzine (D) treats anxiety, all less urgent than sepsis.
The emergency department (ED) nurse performs triage. Which client should the nurse prioritize care for? A client with
- A. hemophilia reporting knee and ankle stiffness with dizziness.
- B. chronic obstructive pulmonary disease (COPD) reporting a productive cough.
- C. chronic pericarditis reporting intermittent chest pain during inspiration.
- D. pain over the cheek radiating to the teeth, tenderness to percussion over the sinuses.
Correct Answer: A
Rationale: Hemophilia with joint stiffness and dizziness (A) suggests possible internal bleeding or anemia, a life-threatening emergency requiring immediate prioritization. COPD cough (B), pericarditis pain (C), and sinusitis (D) are less acute.