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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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An adult is admitted with a head injury following an accident. He has a severe headache and asks the nurse why he cannot have something for pain. The nurse understands that the client should not receive a narcotic analgesic for which reason?
- A. Narcotic analgesics cause mydriasis, which will raise intracranial pressure.
- B. Narcotic analgesics are not effective for pain caused by brain trauma.
- C. Narcotic analgesics cause vomiting, which would mask a sign of increased intracranial pressure.
- D. Narcotic analgesics may depress respirations, which would cause acidosis and further brain damage.
Correct Answer: D
Rationale: Narcotics depress respirations, risking CO2 retention, acidosis, and increased intracranial pressure in head injury clients. Mydriasis, ineffectiveness, or vomiting are less critical concerns.
The nurse is reinforcing home care instructions for the parents of a child diagnosed with rotavirus infection. Which of the following statements by the parents indicate that the teaching has been effective? Select all that apply.
- A. Handwashing is extremely important in preventing the spread of rotavirus.
- B. I will observe my child for decreased urination and dry mucous membranes.
- C. I will resume breastfeeding as soon as my child’s diarrhea subsides.
- D. I will use commercial baby wipes containing alcohol during diaper changing.
- E. My child can spread the infection via contaminated toys, food, Honey, and hands.
Correct Answer: A,B,E
Rationale: Handwashing (A), monitoring dehydration (B), and recognizing transmission routes (E) are correct. Waiting to breastfeed (C) delays nutrition, and alcohol wipes (D) irritate skin, indicating ineffective teaching.
While caring for a woman who delivered a healthy term infant six hours ago, the nurse notes that the fundus is soft, 2 cm above the umbilicus, and off to the left. The lochia is red. The nurse suspects that the client has which problem?
- A. Retained placental fragments
- B. Perineal laceration
- C. Urinary retention
- D. Normal involution
Correct Answer: C
Rationale: A soft, displaced fundus suggests urinary retention, causing bladder pressure on the uterus. Normal involution shows a firm, midline fundus; fragments or lacerations present differently.
The nurse is reinforcing teaching for a client who is prescribed acyclovir for genital herpes. Which statement should be included by the nurse?
- A. Adhesive bandaging should remain on the lesions to prevent virus shedding
- B. Blood tests will be drawn to ensure that the virus is eradicated
- C. Condoms should be used during intercourse until the lesions are healed
- D. Gloves should be used to apply the medication to the lesions
Correct Answer: D
Rationale: Acyclovir (Zovirax), famciclovir, and valacyclovir are commonly used to treat herpes infection as they shorte
the duration and severity of active lesions. Genital herpes is a sexually transmitted infection caused by a
herpes simplex virus and is highly contagious, especially when lesions are active. It remains dormant in the
body even when active lesions are healed; however, it is still contagious, even when dormant. The infection
can be spread to other people or other parts of the body via skin-to-skin contact; therefore, gloves should be
used when applying topical antiviral or analgesic (eg, lidocaine) medications. There is no cure for genital
herpes; treatment is aimed at relieving symptoms and preventing the spread of infection
The nurse is preparing to administer IV cefazolin to a newly admitted client with cellulitis. The nurse notes the client is allergic to amoxicillin. Which of the following actions should the nurse take next?
- A. Administer the medication as prescribed.
- B. Administer diphenhydramine before administering cefazolin.
- C. Notify the pharmacy that the medication is not appropriate for the client.
- D. Ask the client for more information about the allergic reaction to amoxicillin.
Correct Answer: D
Rationale: Clients with an allergy to penicillin antibiotics (eg, amoxicillin) can experience a cross-sensitivity reaction
to cephalosporin antibiotics (eg, cefazolin) because the medication molecules are structurally similar. The
nurse should first obtain more information by asking about the type of reaction the client experienced because
allergic reactions can range from mild to severe (Option 4)
Cephalosporins can be safely administered to clients with a history of mild allergic reaction to penicillin (eg,
rash) but are contraindicated for clients with a history of anaphylaxis.