Nokea
The nurse is caring for a child in the emergency department (ED) who sustained a bite from a rabid animal. The nurse should take which initial action
- A. Complete a detailed wound assessment
- B. Cleanse the wound with soap and water
- C. Obtain a prescription for an antibiotic
- D. Report the bite to animal control
Correct Answer: B
Rationale: Cleansing the wound with soap and water (B) is the initial action for a rabid animal bite to reduce viral load and infection risk, per CDC recommendations. Wound assessment (A), antibiotics (C), and reporting (D) follow initial cleaning.
You may also like to solve these questions
The nursing supervisor has implemented a new assignment system for nursing staff. In order to reduce resistance to this new system, the nurse manager should
- A. Provide incentives to foster the change
- B. Allow nursing staff to discuss potential concerns
- C. Provide statistical support for the change
- D. Detail the changes in a multimedia presentation
Correct Answer: B
Rationale: Allowing staff to discuss concerns (B) reduces resistance by fostering open communication and involvement, addressing potential barriers. Incentives (A), statistics (C), and presentations (D) are supportive but less effective without staff input.
The nurse has been made aware of the following client situations. The nurse should initially follow up with the client who
- A. had an adrenalectomy 24 hours ago and has become restless with the most recent blood pressure (BP) of 98/60 mm Hg.
- B. has a continuous infusion of heparin for the treatment of a pulmonary embolism (PE) and has an activated partial thromboplastin time (aPTT) of 70 seconds (normal 30-40 seconds).
- C. is receiving mechanical ventilation to treat hospital-acquired pneumonia (HAP) and was last suctioned via the endotracheal (ET) tube two hours ago.
- D. has a newly placed chest tube for hemothorax and has had 45 mL of bright red drainage in the past hour.
Correct Answer: A
Rationale: Restlessness and BP of 98/60 mm Hg 24 hours post-adrenalectomy (A) suggest possible adrenal crisis or hypovolemia, a life-threatening emergency requiring immediate follow-up. Elevated aPTT on heparin (B) indicates therapeutic anticoagulation, recent suctioning (C) is routine, and 45 mL chest tube drainage (D) is within normal limits, all less urgent.
The RN is the only RN in the assisted care facility on a busy evening shift. Of the following tasks, which ones can be safely delegated to an experienced LPN/LVN? Select all that apply.
- A. Completing an admission assessment on a new patient
- B. Administering routine oral medications to stable patients.
- C. Removal of a urinary catheter
- D. Completing a dressing change
- E. Administering an initial dose of a new medication to a patient.
Correct Answer: B, C, D
Rationale: Routine oral medications (B), urinary catheter removal (C), and dressing changes (D) are within an experienced LPN’s scope for stable patients. Admission assessments (A) and initial new medication doses (E) require RN judgment due to potential instability or adverse reactions.
The charge nurse is reviewing assignments on the nursing unit for the upcoming shift. Which room assignment should be changed based on the nurse assigned? See the exhibit. Select all that apply.
- A. Room 1
- B. Room 2
- C. Room 3
- D. Room 4
- E. Room 5
- F. Room 6
- G. Room 7
Correct Answer: B,E,F
Rationale: the client with angina and ST-segment changes should be assigned to the RN because of this client's clinical unpredictability. Angina accompanied by ST-segment changes is a worrisome sign of acute coronary syndrome. This assignment needs to be modified so it is assigned to an RN.
Choice E is correct. The client with ARDS requires a high level of care. ARDS is a potentially fatal condition that may require mechanical ventilation. This assignment needs to be modified so it is assigned to an RN.
Choice F is correct. The client with a pulmonary embolism receiving a continuous infusion of heparin should be assigned to the RN. A pulmonary embolism has a degree of unpredictability in its course, and a continuous infusion of heparin will be titrated based on the client's activated partial thromboplastin time (aPTT). Titration of infusions is within the scope of an RN. This assignment needs to be modified so it is assigned to an RN.t
The emergency department (ED) nurse is caring for a client admitted with diabetic ketoacidosis (DKA). Which clinical data requires immediate follow-up?
- A. Respiratory rate (RR) 23/minute
- B. Capillary blood glucose 319 mg/dL (17.70 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]
- C. Mean arterial pressure (MAP) 51 mm Hg
- D. PaO2 90 mm Hg [80-100 mm Hg]
Correct Answer: C
Rationale: A MAP of 51 mm Hg in DKA (C) indicates severe hypotension and organ hypoperfusion, requiring immediate fluid resuscitation. RR 23 (A) and glucose 319 (B) are expected in DKA, and PaO2 90 (D) is normal, none requiring immediate action.