Nokea
The nurse is teaching the client home care instructions for a reimplanted finger after a traumatic amputation. Which information should the nurse include in the teaching?
- A. Perform range-of-motion exercises weekly.
- B. Smoking may be resumed if it does not cause nausea.
- C. Protect the finger and be careful not to reinjure the finger.
- D. An elevated temperature is the only reason to call the HCP.
Correct Answer: C
Rationale: Protecting the reimplanted finger prevents reinjury, critical for healing. ROM timing varies, smoking impairs circulation, and multiple symptoms warrant HCP contact.
You may also like to solve these questions
Which equipment must be immediately brought to the client’s bedside when a code is called for a client who has experienced a cardiac arrest?
- A. A ventilator.
- B. A crash cart.
- C. A gurney.
- D. Portable oxygen.
Correct Answer: B
Rationale: A crash cart contains defibrillator, medications, and airway equipment, essential for cardiac arrest. Ventilator, gurney, and oxygen are secondary or supportive.
The triage nurse has placed a disaster tag on the client. Which action warrants immediate intervention by the nurse?
- A. The nurse documents the tag number in the disaster log.
- B. The unlicensed assistive personnel documents vital signs on the tag.
- C. The health-care provider removes the tag to examine the limb.
- D. The LPN securely attaches the tag to the client’s foot.
Correct Answer: C
Rationale: Removing the disaster tag disrupts identification and tracking, requiring intervention. Documentation, vital signs, and attachment are appropriate.
The female client presents to the emergency department with facial lacerations and contusions. The spouse will not leave the room during the assessment interview. Which intervention should be the nurse’s first action?
- A. Call the security guard to escort the spouse away.
- B. Discuss the injuries while the spouse is in the room.
- C. Tell the spouse the police will want to talk to him.
- D. Escort the client to the bathroom for a urine specimen.
Correct Answer: D
Rationale: Escorting the client to the bathroom provides a private opportunity to assess for abuse safely. Security, discussing injuries, or mentioning police may escalate the situation.
The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse?
- A. Vital signs T 100.4°F, P 104, R 26, and BP 102/60.
- B. A white blood cell count of 18,000/mm3.
- C. A urinary output of 90 mL in the last four (4) hours.
- D. The client complains of being thirsty.
Correct Answer: C
Rationale: Urinary output of 90 mL/4 hours = 22.5 mL/hour, below 30 mL/hour, indicating renal hypoperfusion, requiring immediate intervention. Fever, tachycardia, and elevated WBC are expected; thirst is less urgent.
According to the North Atlantic Treaty Organization (NATO) triage system, which situation is considered a level red (Priority 1)?
- A. Injuries are extensive and chances of survival are unlikely.
- B. Injuries are minor and treatment can be delayed hours to days.
- C. Injuries are significant but can wait hours without threat to life or limb.
- D. Injuries are life threatening but survivable with minimal interventions.
Correct Answer: D
Rationale: NATO red (Priority 1) indicates life-threatening injuries survivable with immediate intervention (e.g., tension pneumothorax). Extensive injuries are black, minor are green, and significant but delayed are yellow.