Nokea
The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority?
- A. Starting an IV
- B. Applying oxygen
- C. Obtaining blood gases
- D. Medicating the client for pain
Correct Answer: B
Rationale: Applying oxygen is the priority to ensure airway patency and oxygenation in a client with facial and neck burns, which can cause airway compromise.
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The nurse is assessing a client who is 36 hours postpartum. Which of the following findings would indicate a need for further evaluation?
- A. Fundus firm and 2 cm below the umbilicus.
- B. Moderate lochia serosa.
- C. Mild perineal discomfort.
- D. Temperature of 100.4°F (38°C).
Correct Answer: D
Rationale: a temperature of 100.4°F may indicate infection, such as endometritis, and requires further evaluation
Following surgical repair of a fractured femur, a client's hemoglobin falls to 7.4 and the physician orders one unit of packed red blood cells (250 mL) to be administered over two hours with a drop factor of 10 drops/mL. What flow rate (drops per minute) is needed? Record by rounding to the nearest whole number.
Correct Answer: 21
Rationale: To calculate the flow rate: (Volume X Drop factor)/ Time in minutes. Volume is 250 mL, drop factor is 10 drops/mL, time is 2 hours = 120 minutes. Thus, (250 X 10)/ 120 = 2,500/ 120 ≈ 20.83, rounded to 21 drops/minute.
Vitamin K is administered to the newborn shortly after birth for which of the following reasons?
- A. To stop hemorrhage
- B. To treat infection
- C. To replace electrolytes
- D. To facilitate clotting
Correct Answer: D
Rationale: Vitamin K is given to newborns to facilitate clotting, preventing hemorrhagic disease due to low vitamin K levels.
A client with adult respiratory distress syndrome has been placed on mechanical ventilation with PEEP. Which finding would indicate to the nurse that the client is experiencing the undesirable effect of an increase in airway and chest pressure?
- A. A PO2 of 88
- B. Rales on auscultation
- C. Blood pressure decrease to 90/48 from 120/70
- D. A decrease in spontaneous respirations
Correct Answer: C
Rationale: PEEP can increase intrathoracic pressure, reducing venous return and causing hypotension (e.g., BP drop to 90/48), an undesirable effect requiring intervention.
The nursing assistant finds a client on the floor. Once the client is safe, which of the following should the nurse do next?
- A. document the event in the client's medical record only
- B. document the event in the client's medical record and file an incident report
- C. document the event in the client's medical record and have the nursing assistant file an incident report
- D. have the nursing assistant file an incident report
Correct Answer: B
Rationale: Falls require documentation in the medical record and an incident report to track safety issues and ensure follow-up.