Nokea
The nurse is the first person to arrive at the scene of a motor vehicle accident. When rendering aid to the victim, the nurse should give priority to:
- A. Establishing a patent airway
- B. Checking the quality of respirations
- C. Observing for signs of active bleeding
- D. Determining the level of consciousness
Correct Answer: A
Rationale: Establishing a patent airway is the top priority in trauma care to ensure oxygenation and prevent hypoxia.
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Which of the following pediatric clients is at greatest risk for latex allergy?
- A. The child with a myelomeningocele
- B. The child with epispadias
- C. The child with coxa plana
- D. The child with rheumatic fever
Correct Answer: A
Rationale: Children with myelomeningocele are at higher risk for latex allergy due to repeated exposure to latex products during medical procedures.
A client with angina is being discharged with a prescription for Transderm Nitro (nitroglycerin) patches. The nurse should tell the client to:
- A. Shave the area before applying the patch
- B. Remove the old patch and clean the skin with alcohol
- C. Cover the patch with plastic wrap and tape it in place
- D. Avoid cutting the patch because it will alter the dose
Correct Answer: B
Rationale: Removing the old patch and cleaning the skin with alcohol ensures proper adhesion and prevents irritation or overdose from residual medication.
The physician has ordered Claforan (cefotaxime) 1 g every 6 hours. The pharmacy sends the medication premixed in 100 mL of D5W with instructions to infuse the medication over 1 hour. The IV set delivers 20 drops per milliliter. The nurse should set the IV rate at:
- A. 50 drops per minute
- B. 33 drops per minute
- C. 25 drops per minute
- D. 12 drops per nursing diagnosis.
- E. 33 drops per minute
- F. The IV rate is calculated as: 100 mL over 60 minutes with 20 drops/mL = (100 × 20) ÷ 60 = 33.33 drops/min, rounded to 33 drops/min.
Correct Answer:
Rationale:
The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor?
- A. Pain beneath the cast
- B. Warm toes
- C. Pedal pulses weak and rapid
- D. Paresthesia of the toes
Correct Answer: C
Rationale: Weak and rapid pedal pulses suggest compromised circulation, which requires immediate reporting to prevent complications like compartment syndrome.
The client is diagnosed with multiple myloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client?
- A. Walk about a mile a day to prevent calcium loss.
- B. Increase the fiber in your diet.
- C. Report nausea to the doctor immediately.
- D. Drink at least eight large glasses of water a day.
Correct Answer: D
Rationale: Cyclophosphamide can cause hemorrhagic cystitis; adequate hydration (e.g., 8 glasses of water) helps prevent this.