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The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness. The client is flushed, sweating, nauseated, and slightly tachycardic. Which action is most appropriate at this time?
- A. Call emergency medical services and place ice packs on the client’s axilla and groin
- B. Encourage the client to leave the venue to visit a health care provider
- C. Evaluate whether the client may be intoxicated
- D. Move the client to an air-conditioned booth and provide a cool sports drink
Correct Answer: D
Rationale: Symptoms suggest heat exhaustion. Moving to a cool area and providing fluids (D) is the first step. EMS (A) is premature, leaving (B) delays care, and intoxication (C) is not indicated.
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The nurse is planning care for a client who must remain in bed for several weeks. Which action will do most to prevent the development of pressure ulcers?
- A. Performing range-of-motion exercises
- B. Deep breathing and coughing
- C. Keeping the feet against a footboard
- D. Changing position in bed frequently
Correct Answer: D
Rationale: Frequent position changes relieve pressure on bony prominences, preventing pressure ulcers. ROM, breathing, or footboards address other complications.
Which client is most at risk for methicillin-resistant Staphylococcus aureus infection?
- A. 15-year-old student athlete in the emergency department with a closed femur fracture
- B. 46-year-old client on the medical-surgical unit after a laparoscopic appendectomy
- C. 72-year-old client who received a permanent pacemaker 24 hours ago
- D. 80-year-old client with a hemodialysis catheter who lives in a long-term care facility
Correct Answer: D
Rationale: The 80-year-old with a hemodialysis catheter in a long-term care facility (D) is at highest risk for MRSA due to invasive devices, frequent healthcare exposure, and communal living. Others (A, B, C) have lower risk profiles.
A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?
- A. Drink small amounts of liquids frequently
- B. Eat the evening meal just before retiring
- C. Take sodium bicarbonate and water after each meal
- D. Sleep with head propped on several pillows
Correct Answer: D
Rationale: Sleep with head propped on several pillows. Heartburn is a burning sensation caused by regurgitation of gastric contents. It is best relieved by sleeping position, eating small meals, and not eating before bedtime.
The nurse is reviewing lifestyle and nutritional strategies to help cables symptoms in a client with newly diagnosed gastroesophageal reflux disease. Which strategies should the nurse include? Select all that apply.
- A. Choose foods that are low in fat
- B. Do not consume any foods containing dairy
- C. Eat three large meals a day and minimize snacking
- D. Limit or eliminate the use of alcohol and tobacco
- E. Try to avoid caffeine, chocolate, and peppermint
Correct Answer: A,D,E
Rationale: GERD management focuses on reducing esophageal irritation. Low-fat foods (A) reduce gastric acid secretion and reflux risk. Limiting alcohol and tobacco (D) prevents lower esophageal sphincter relaxation and mucosal irritation. Avoiding caffeine, chocolate, and peppermint (E) minimizes sphincter relaxation. Dairy (B) is not universally contraindicated unless lactose intolerance is present. Large meals (C) increase gastric pressure, worsening reflux.
The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended?
- A. Seizures
- B. Withdrawal
- C. Craving
- D. Marked tolerance
Correct Answer: B
Rationale: Withdrawal. Early withdrawal symptoms, including nausea and tremor, appear within hours of reducing alcohol intake.