Nokea
The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate?
- A. Schedule the therapy thirty minutes after meals
- B. Teach the child not to cough during the treatment
- C. Continue the percussion to the rib cage area
- D. Place the child in a prone position for the therapy
Correct Answer: C
Rationale: Continue the percussion to the rib cage area. Percussion should target the rib cage to mobilize secretions effectively.
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Which statements involve acceptable use of an abbreviation, symbol, or dose designation in documentation? Select all that apply.
- A. 7 cm x 3 cm x 1 cm stage II decubitus noted on left shin.
- B. 40 u SSRI administered to cover capillary glucose of 160 mg/dL.
- C. Dose of 0.5 mg hydromorphone administered and the client feels better.
- D. 4 Maalox 5 mL PO administered pc as requested for c/o heartburn.
- E. Spouse voiced understanding of home urinary catheterization QID.
Correct Answer: A
Rationale: Metric units (A), decimal doses (C), and QID (E) are clear and acceptable. 'u' (B) risks confusion with '0,' and 'pc' with 'c/o' (D) are ambiguous, per safety standards.
The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness. The client is flushed, sweating, nauseated, and slightly tachycardic. Which action is most appropriate at this time?
- A. Call emergency medical services and place ice packs on the client’s axilla and groin
- B. Encourage the client to leave the venue to visit a health care provider
- C. Evaluate whether the client may be intoxicated
- D. Move the client to an air-conditioned booth and provide a cool sports drink
Correct Answer: D
Rationale: Symptoms suggest heat exhaustion. Moving to a cool area and providing fluids (D) is the first step. EMS (A) is premature, leaving (B) delays care, and intoxication (C) is not indicated.
Laboratory reference ranges
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)
A category 4 hurricane has affected a rural, local health care system, creating a significant increase in emergency department admissions. Which of the following clients should the nurse anticipate as the priority for intervention?
- A. Client with status asthmaticus and a pulse oximetry reading of 89%
- B. Client with diabetes mellitus reporting a headache after being involved in a minor motor vehicle collision
- C. Client who is 11 weeks pregnant, has gestational diabetes, and nausea and vomiting over the past 2 days
- D. Client with diabites mellitus with a serum glucose level of 690 mg/dl (38.3 mmol/L ,abdominal pain, and fatigue)
Correct Answer: A
Rationale: Status asthmaticus with 80% pulse oximetry (A) indicates severe hypoxia, requiring immediate intervention to prevent respiratory failure. Headache post-collision (B) and nausea in pregnancy (C) are less acute, as they do not indicate immediate life-threatening conditions.
A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What is the most appropriate response by the nurse?
- A. Encourage the visitor to lie down to see if symptoms change
- B. Initiate protocol to assist the visitor to the emergency department
- C. Proceed to take the visitor's blood pressure
- D. Suggest that the visitor call the health care provider
Correct Answer: B
Rationale: Sudden headache and hemibody numbness suggest a possible stroke, a medical emergency requiring immediate evaluation. Initiating protocol to transfer the visitor to the emergency department (B) ensures timely care. Lying down (A), taking blood pressure (C), or calling a provider (D) delays critical intervention.
The nurse is observing a staff member preparing regular insulin and NPH insulin in 1 syringe. The nurse should intervene if the staff member is observed
- A. Drawing up the NPH insulin after drawing up the regular insulin
- B. Injecting air into the regular insulin vial after injecting air into the NPH insulin vial
- C. Allowing the tip of the needle to touch the NPH insulin vial while injecting air into the vial
- D. cleaning the tops of both insulin vials with an alcohol swab prior to inserting the needle
Correct Answer: A
Rationale: When mixing regular and NPH insulin, regular (clear) insulin is drawn first to prevent contamination with NPH (cloudy) insulin, which could alter its action. Drawing NPH after regular (A) is incorrect and requires intervention. Injecting air into vials (B) follows the same order (NPH then regular), which is correct. Needle contact with the vial (C) is poor technique but less critical than incorrect insulin order.