Nokea
A nurse is caring for a client who ingested a poison and is now having seizures. Which of the following is the priority action the nurse should take?
- A. Maintain the patency of the client's airway.
- B. Identify the poison the client ingested.
- C. Measure the client's blood pressure.
- D. Position the client on her side.
Correct Answer: A
Rationale: Airway patency is the priority during seizures to prevent aspiration and ensure adequate oxygenation.
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A nurse is collecting data about a client's circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?
- A. Brachial
- B. Carotid
- C. Femoral
- D. Popliteal
Correct Answer: B
Rationale: The correct answer is B: Carotid. Checking the carotid pulse bilaterally simultaneously can lead to a temporary decrease in blood flow to the brain, potentially causing dizziness or fainting. It is important to assess one carotid pulse at a time to ensure adequate blood supply to the brain. Checking the brachial, femoral, and popliteal pulses bilaterally at the same time is safe as it does not pose a risk of compromising blood flow to critical organs.
A nurse is caring for a client who had a severe traumatic brain injury 3 weeks ago, remains unconscious, and is unlikely to recover. While bathing the client, the assistive personnel (AP) talks to him about current events. The client's partner asks the nurse why the AP talks to the client. Which of the following responses should the nurse make?
- A. I'm really not sure why the assistant is talking to him. Perhaps you should ask her.
- B. Although your partner is not responding to us, he might still be able to hear.
- C. Don't let that concern you. She talks to all her clients, no matter what.
- D. She is an excellent caregiver. She has many others to care for, but she takes the time to talk to your partner.
Correct Answer: B
Rationale: The correct answer is B: Although your partner is not responding to us, he might still be able to hear. This response is correct because research shows that comatose patients can still hear and process information. Talking to the patient can provide comfort, familiarity, and potentially stimulate brain activity.
Choices A, C, and D are incorrect because they do not address the potential benefit of talking to the unconscious patient. A deflects the question, C generalizes the behavior, and D praises the caregiver without explaining the rationale behind talking to the patient.
In summary, choice B is the best response as it acknowledges the potential for the unconscious patient to hear and emphasizes the importance of continuing communication for the patient's well-being.
A nurse in an urgent care clinic is preparing to remove skin sutures from a client. Which of the following actions should the nurse take?
- A. Remove loose sutures first
- B. Cut below the suture knot
- C. Use clean bandage scissors
- D. Lift sutures from the skin with a sterile needle
Correct Answer: B
Rationale: Cutting below the suture knot prevents external contamination and reduces infection risk.
A nurse is caring for a client who is postoperative. The nurse should recognize that which of the following methods is the most reliable source when determining the intensity of the client's pain?
- A. Vital sign measurement
- B. Client's self-report of pain
- C. Visual observation for nonverbal signs of pain
- D. Nature of invasiveness of the surgical procedure
Correct Answer: B
Rationale: The correct answer is B: Client's self-report of pain. This is the most reliable source for determining the intensity of the client's pain because pain is a subjective experience and can vary greatly among individuals. The client is the best source to accurately describe their pain level, location, and quality. Vital sign measurements (A) may provide some indication of pain, but they are not as accurate as the client's self-report. Visual observation (C) may be helpful, but it can be subjective and may not always correlate with the client's actual pain level. The nature of invasiveness of the surgical procedure (D) may give some indication of potential pain level, but it does not directly measure the client's current pain intensity.
A young adult tells the nurse in the provider's office that he is concerned about the amount of sleep he is getting. The nurse should explain that which of the following durations is the average recommendation for sleep for a young adult?
- A. 8 hr
- B. 11 hr
- C. 12 hr
- D. 14 hr
Correct Answer: A
Rationale: The correct answer is A: 8 hr. The average recommendation for sleep for a young adult is typically around 7-9 hours per night. This amount allows for adequate rest and helps maintain overall health and well-being. Choice B (11 hr), C (12 hr), and D (14 hr) are excessive amounts of sleep that are not necessary for young adults and could potentially lead to negative effects such as grogginess or difficulty waking up. Therefore, option A is the most appropriate and balanced choice for a young adult's sleep duration.