Nokea
The nurse observes the following patients in the emergency department (ED). The FIRST patient the nurse should see is the
- A. 34-year-old man with a distended abdomen and splenomegaly.
- B. 8-month-old infant with facial ecchymosis who is crying loudly.
- C. 12-year-old boy with a possible fractured ankle.
- D. 44-year-old woman with possible whiplash from an automobile accident.
Correct Answer: A
Rationale: possibility of internal bleeding, life-threatening situation
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The nurse is caring for a client who is receiving IV fluids at 150 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 140/90 mmHg.
- B. Heart rate of 90 bpm.
- C. Crackles in the lung bases.
- D. Urine output of 100 mL/hour.
Correct Answer: C
Rationale: Crackles in the lung bases suggest fluid overload, a serious complication of IV fluids, potentially leading to pulmonary edema. Options A, B, and D are normal or less concerning: blood pressure 140/90 mmHg and heart rate 90 bpm are stable, and urine output 100 mL/hour is adequate.
The nurse is caring for a patient recovering from abdominal surgery. While ambulating, the patient complains to the nurse that she has a dull ache in her left leg. The nurse should
- A. place the patient on bedrest and elevate the foot of the bed six inches.
- B. ask the patient to remain in bed and place a pillow under the knee to elevate her left leg.
- C. ambulate the patient as directed to prevent complications of bedrest.
- D. obtain thigh-high compression or elastic stockings and continue ambulating the patient.
Correct Answer: A
Rationale: promotes venous return and decreases venous pressure relieving pain and edema
A client has come to the clinic for a hepatitis B vaccine and asks if he has to be re-vaccinated after his first injection. Which of the following responses by the nurse is BEST?
- A. A booster shot is required yearly.
- B. Additional injections are given at one and six months.
- C. Repeat doses are given at two and four months.
- D. Revaccination is not required.
Correct Answer: B
Rationale: hepatitis B vaccine is repeated at one and six months
The nurse is caring for a schizophrenic client who has become increasingly withdrawn to the point of mutism. The MOST important nursing approach at this time would be to
- A. ignore the client until he is ready to respond.
- B. sit with the client for brief periods of time.
- C. read to the client in a quiet area of the unit.
- D. encourage the client to play dominos with the group.
Correct Answer: B
Rationale: nurse should maintain contact with client but not make demands to communicate or participate in activities
A client who is a gravida 2, para 1 has been admitted for induction of labor with oxytocin (Pitocin).
It would be MOST important for the nurse to take which of the following actions?
- A. Mix Pitocin in D5W, begin at 5 mg/cc as primary IV to gravity flow.
- B. Decrease the rate/flow of Pitocin if the fetal heart rate is below 150.
- C. Piggyback the Pitocin into the mainline IV and maintain the flow by gravity.
- D. Start an IV line and piggyback the Pitocin with an infusion pump.
Correct Answer: D
Rationale: Strategy: The topic of the question is unstated. Read the answer choices for clues. (1) Pitocin should be a secondary infusion (2) normal range for fetal heart tones is 120 to 160 beats per minute (3) rate should be maintained by an infusion pump (4) correct-Pitocin should always be a secondary infusion controlled by an IV pump