Nokea
The nurse is caring for an adult being admitted with a head injury. The nurse plans to place the client in which position?
- A. Prone
- B. Supine
- C. Semi-reclining
- D. Upright
Correct Answer: C
Rationale: Semi-reclining (30-45 degrees) reduces intracranial pressure in head injury by promoting venous drainage, unlike prone, supine, or upright positions.
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The nurse is caring for a client who has no pulse and is experiencing the cardiac rhythm in the ECG strip shown below. The client has a do not attempt resuscitation directive. The health care provider (HCP) orders initiation of resuscitative measures. Which of the following actions should the nurse take?
- A. Initiate chest compressions.
- B. Clarify the order with the HCP.
- C. Prepare the client for defibrillation.
- D. Verify the client's wishes with the family.
Correct Answer: B
Rationale: A client with a Do Not Attempt Resuscitation (DNAR) or Do Not Resuscitate (DNR) directive has legally chosen not to receive resuscitative measures, such as CPR or defibrillation, in the event of cardiac arrest. The nurse has an ethical and legal obligation to honor the client's advanced directive.
The nurse is assessing a 12 year-old who has hemophilia A. Which finding would the nurse anticipate?
- A. An excess of red blood cells
- B. An excess of white blood cells
- C. A deficiency of clotting factor VIII
- D. A deficiency of clotting factors VIII and IX
Correct Answer: C
Rationale: Hemophilia A is characterized by an absence or deficiency of Factor VIII.
The nurse is caring for a client with Kawasaki disease. Which of the following actions would be a priority for the nurse to take?
- A. Monitor the client for gallop heart sounds and decreased urine output.
- B. Provide a quiet, nonstimulating, restful environment for the client.
- C. Apply cool compresses to the skin of the client's hands and feet.
- D. Offer the client soft foods and adequate amounts of clear liquids.
Correct Answer: B
Rationale: A quiet, restful environment reduces irritability and stress in Kawasaki disease, promoting recovery. Monitoring heart sounds/urine output is secondary, as cardiac complications are less immediate. Cool compresses and soft foods are less critical.
The nurse is collecting data on a 2-day-old infant with suspected Hirschsprung disease. Which findings should the nurse anticipate? Select all that apply.
- A. Bright red bleeding from anus
- B. Distended abdomen
- C. Has not passed stool (meconium)
- D. Nonbilious vomiting
- E. Refuses to feed
Correct Answer: B,C,D
Rationale: Hirschsprung disease causes intestinal obstruction, leading to a distended abdomen, failure to pass meconium, and nonbilious vomiting. Bright red bleeding suggests other causes (e.g., fissure). Feeding refusal is less specific.
During the discharge teaching of a client with Buerger's disease, the nurse should teach the client:
- A. Exercises for improving vascular return from the lower extremities
- B. The importance of wearing mittens or gloves
- C. Dietary choices for reducing triglycerides
- D. The role of weight bearing exercises in preventing bone loss
Correct Answer: A
Rationale: Exercises to improve vascular return, such as ankle pumps, help manage Buerger's disease by promoting circulation in the extremities.