Nokea
The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first
- A. Assess the client's airway
- B. Call for help
- C. Establish that the client is unresponsive
- D. See if anyone saw the client fall
Correct Answer: C
Rationale: Establish that the client is unresponsive. This is the first step in CPR to determine the need for further action.
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The physician has ordered a sterile urine specimen to be collected from a client who has a Foley catheter. To obtain a sterile urine specimen, the nurse should:
- A. Use a luer lock syringe and withdraw from the bulb port.
- B. Disconnect the catheter from the drainage bag.
- C. Open the urine bag and remove the specimen.
- D. Use a syringe and withdraw from the catheter port.
Correct Answer: D
Rationale: Withdrawing from the catheter port with a syringe ensures a sterile specimen. Other methods risk contamination.
The nurse is assessing a newborn delivered at home by a client addicted to heroin. Which of the following would the nurse expect to observe?
- A. Hypertonic neuro reflex
- B. Immediate CNS depression
- C. Lethargy and sleepiness
- D. Jitteriness at 24-48 hours
Correct Answer: D
Rationale: Jitteriness at 24-48 hours. Withdrawal signs may not be evident for 1-2 days after birth. Irritability and poor feeding also are evident.
Which observation in the newborn of a diabetic mother would require immediate nursing intervention?
- A. Crying
- B. Wakefulness
- C. Jitteriness
- D. Yawning
Correct Answer: C
Rationale: Jitteriness in a newborn of a diabetic mother may indicate hypoglycemia, requiring immediate intervention. Crying, wakefulness, and yawning are normal behaviors, so A, B, and D are incorrect.
The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet
- A. High in carbohydrates and proteins
- B. Low in carbohydrates and proteins
- C. High in carbohydrates, low in proteins
- D. Low in carbohydrates, high in proteins
Correct Answer: A
Rationale: High in carbohydrates and proteins. This diet supports energy needs and compensates for malabsorption in cystic fibrosis.
The nurse is caring for a client who is terminally ill. When the client dies, the nurse should:
- A. Pronounce the client dead and call the doctor.
- B. Contact the coroner.
- C. Tag the body prior to the funeral home notification.
- D. Request an autopsy.
Correct Answer: C
Rationale: Tagging the body ensures proper identification before transfer to the funeral home. Nurses do not pronounce death, coroner contact depends on policy, and autopsies are not routinely requested.