Nokea
The nurse is caring for a client hospitalized with bipolar disorder, manic phase who is taking lithium. Which of the following snacks would be best for the client with mania?
- A. Potato chips
- B. Diet cola
- C. Apple
- D. Milkshake
Correct Answer: C
Rationale: An apple is a healthy, low-sodium snack, suitable for a client on lithium, as high sodium foods like potato chips can affect lithium levels.
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The nurse is caring for a 9-year-old child admitted with asthma. Upon the morning rounds, the nurse finds an O2 sat of 78%. Which of the following actions should the nurse take first?
- A. Notify the physician
- B. Do nothing; this is a normal O2 sat for a 9-year-old
- C. Apply oxygen
- D. Assess the child's pulse
Correct Answer: C
Rationale: An O2 sat of 78% indicates severe hypoxemia, so applying oxygen is the first action to stabilize the child.
A client with a gastrointestinal bleed has an NG tube to low continuous wall suction. Which technique is the correct procedure for the nurse to utilize when assessing bowel sounds?
- A. Insert 10 mL of air in the NG tube and listen over the abdomen with a stethoscope
- B. Clamp the tube while listening to the abdomen with a stethoscope
- C. Irrigate the tube with 30 mL of NS while auscultating the abdomen
- D. Turn the suction on high and auscultate over the naval area
Correct Answer: B
Rationale: Clamping the NG tube prevents suction noise from interfering with auscultation, allowing accurate assessment of bowel sounds.
The physician has ordered cortisporin ear drops for a 2-year-old. To administer the ear drops, the nurse should:
- A. Pull the ear down and back
- B. Pull the ear straight out
- C. Pull the ear up and back
- D. Leave the ear undisturbed
Correct Answer: A
Rationale: For children under 3, pulling the ear down and back straightens the ear canal for proper administration of ear drops.
A client is admitted to the emergency room with a gunshot wound to the right arm. After dressing the wound and administering the prescribed antibiotic, the nurse should:
- A. Ask the client if he has any medication allergies
- B. Check the client's immunization record
- C. Apply a splint to immobilize the arm
- D. Administer medication for pain
Correct Answer: C
Rationale: Immobilizing the arm with a splint prevents further tissue damage and promotes healing, which is a priority after initial wound care and antibiotic administration. Checking for allergies should have been done prior to administering antibiotics, and pain management, while important, is secondary to stabilization.
A nurse is working in a residential facility when a fire breaks out in one hallway. The nurse and an elderly client are trapped in the client's room and cannot get out. The nurse should
- A. crawl in the closet with the client and shut the door.
- B. open a window in the client's room.
- C. instruct the client to crawl under the bed.
- D. leave the door to the room open.
Correct Answer: B
Rationale: Opening a window provides ventilation and a potential escape route while avoiding smoke inhalation. Keeping the door closed prevents smoke entry, and crawling under the bed or in a closet is unsafe.