Nokea
The nurse is demonstrating the appropriate use of a car seat to a client. The nurse is demonstrating which level of prevention?
- A. Primary
- B. Secondary
- C. Tertiary
- D. Quaternary
Correct Answer: A
Rationale: Car seat education prevents injury, a primary prevention strategy.
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The nurse is caring for a client with suspected placenta previa. The nurse anticipates an order for which diagnostic test to confirm this finding?
- A. Manual cervical exam
- B. Transvaginal ultrasound
- C. Contraction stress test
- D. Nonstress test
Correct Answer: B
Rationale: Transvaginal ultrasound is the safest and most accurate method to confirm placenta previa, avoiding risky manual exams.
The nurse is reviewing newly prescribed medications for assigned clients. Which of the following prescribed medications should the nurse question?
- A. captopril for a client with congestive heart failure
- B. metoprolol for a client with multiple premature ventricular contractions (PVCs)
- C. verapamil for a client with atrial fibrillation
- D. spironolactone for a client with end-stage renal disease
Correct Answer: D
Rationale: Spironolactone can cause hyperkalemia, which is dangerous in end-stage renal disease, and should be questioned.
The nurse is planning a staff educational conference about indwelling urinary catheters. Which of the following information should the nurse include?
- A. Sterile gloves should be used to perform urinary catheter care.
- B. Urinary specimens may be collected from a catheter bag.
- C. You may irrigate a catheter with warm water for poor outflow.
- D. Daily use of soap and water should be used around the urinary meatus.
Correct Answer: D
Rationale: Daily soap and water cleaning around the urinary meatus prevents infection. Sterile gloves are not required, specimens from catheter bags are unreliable, and irrigation requires a prescription.
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 3 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.” Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
Complete the following sentence by choosing from the list of options. The nurse should prioritize obtaining an order for a ___ and ___ to better determine the extent of the client's injuries.
- A. radiograph (x-ray) of the head and neck
- B. electrocardiogram
- C. electroencephalogram
- D. computed tomography scan of the head
- E. hematocrit
- F. platelet count
- G. international normalized ratio
Correct Answer: D, G
Rationale: A CT scan of the head is critical to assess for brain injury, and INR is necessary due to warfarin use and bleeding risk.
The nurse cares for a client immediately following a shoulder reduction procedure with moderate sedation. The nurse assesses the client as restless and irritable. The nurse should take which priority action?
- A. Assess the client for pain
- B. Assess the client's oxygen saturation
- C. Assess the client with the Glasgow Coma Scale (GCS)
- D. Assess the client's lung sounds
Correct Answer: B
Rationale: Restlessness and irritability post-sedation may indicate hypoxia. Assessing oxygen saturation is the priority to ensure airway and breathing stability.