Nokea
The nurse is caring for a client who was in a motor vehicle accident. His blood pressure is dropping rapidly. What should the nurse observe the client for before placing the client in shock position?
- A. Long bone fractures
- B. Air embolus
- C. Head injury
- D. Thrombophlebitis
Correct Answer: C
Rationale: Shock position (legs elevated) is contraindicated in head injury due to increased intracranial pressure risk. Observing for head injury ensures safety before positioning.
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A school-aged child who was diagnosed two weeks ago with hepatitis A.
Which of the following responses by the nurse is BEST?
- A. You must isolate your child at home for two more weeks.
- B. Why don't you speak with the physician about this matter?
- C. Your child may return to school this week.
- D. Your child may return to school in 2 weeks but cannot participate in sports.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) communicable for 2-3 weeks before onset of jaundice and about 1 week after onset of jaundice (2) passing the buck (3) correct-type A hepatitis is not infectious within a week or so after the onset of jaundice, child can return to school (4) can return to school, activity at that time depends on the child's energy level
Which play activity is most appropriate for a 15-month-old with a cyanotic heart defect?
- A. Push-and-pull toy
- B. Mobile
- C. Shape sorter
- D. Pounding board
Correct Answer: B
Rationale: A mobile is a passive activity suitable for a 15-month-old with a cyanotic heart defect, as it avoids exertion, so B is correct. Push-and-pull toys , shape sorters , and pounding boards require more physical effort.
Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice?
- A. When a family member offers information about their loved one
- B. When the client threatens self-harm and harm to others
- C. When the provider requests a copy of the client's history
- D. When a visitor insists that the visitor has been given permission by the client
Correct Answer: B
Rationale: When the client threatens self-harm and harm to others. Confidentiality can be breached to ensure safety, per legal precedents like the Tarasoff decision.
A client is placed on cephalexin monohydrate (Keflex) prophylactically after surgery.
Which of the following foods should the nurse encourage?
- A. Bran cereals and fruits.
- B. Egg whites and lean meats.
- C. Yogurt and acidophilus milk.
- D. Fish and poultry meats.
Correct Answer: C
Rationale: Strategy: The topic of the question unstated. Read the answer choices for clues. (1) unnecessary to encourage (2) unnecessary to encourage (3) correct-these foods will help maintain normal inTest inal flora, which may be altered by the Keflex (4) unnecessary to encourage
A student nurse obtaining an infant's vital signs.
Which of the following actions should the student nurse complete FIRST?
- A. Take an axillary temperature to minimize use of invasive procedures.
- B. Count respirations for 15 seconds and multiply the number by 4.
- C. Count respirations for a minute prior to arousing the infant.
- D. Use a stethoscope with a one-and-a-half-inch diaphragm to count the apical pulse.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) inappropriate to use probe to take axillary temperature (2) should count for a full minute (3) correct-respirations should be counted for one full minute prior to arousing the infant with a temperature probe or stethoscope (4) after infant is stimulated, crying may interfere with accurate evaluation of respirations