Nokea
The nurse working in the emergency department realizes that it would be contraindicated to induce vomiting if someone had ingested which of the following?
- A. Ibuprofen
- B. Aspirin
- C. Vitamins
- D. Gasoline
Correct Answer: D
Rationale: Inducing vomiting after ingesting gasoline (a caustic substance) can cause aspiration or esophageal damage. Vomiting is safer for non-caustic substances like ibuprofen, aspirin, or vitamins.
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A client on the post-op floor underwent surgery 4 days ago. The night nurse reports to the nurse coming on to dayshift that the client complained all night of pain, even though she received every dose of prescribed pain medication. The client currently rates the pain at a 10 out of 10. The day shift nurse should first
- A. call the physician and ask her to prescribe a different medication.
- B. work with the client on alternative pain relief measures such as guided imagery.
- C. administer the next dose of pain medication, but observe the client swallow it to ensure she is really taking the medication.
- D. complete a full head-to-toe assessment on the client.
Correct Answer: D
Rationale: Persistent severe pain post-op suggests a complication (e.g., infection, hemorrhage). A full assessment is the priority to identify the cause before adjusting treatment.
Which cephalic presentation is most common during delivery of a neonate?
- A. Vertex
- B. Face
- C. Military
- D. Brow
Correct Answer: A
Rationale: Vertex presentation (A), with the head flexed and occiput leading, is the most common (95%) during delivery.
The physician has ordered 2 units of whole blood for a client following surgery. To provide for client safety, the nurse should:
- A. Obtain a signed permit for each unit of blood
- B. Use a new administration set for each unit transfused
- C. Administer the blood using a $Y$ connector
- D. Check the blood type and Rh factor three times before initiating the transfusion
Correct Answer: B
Rationale: Using a new administration set for each unit prevents contamination and ensures accurate delivery, enhancing transfusion safety.
Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
- A. Oxygen saturation
- B. Respiratory rate
- C. Breath sounds
- D. Arterial blood gases
Correct Answer: C
Rationale: Adventitious breath sounds (e.g., rhonchi or gurgling) indicate mucus obstruction, making suctioning necessary to clear the airway.
A client admitted with transient ischemia attacks has returned from a cerebral arteriogram. The nurse performs an assessment and finds a newly formed hematoma in the right groin area. What is the nurse's initial action?
- A. Apply direct pressure to the site
- B. Check the pedal pulses on the right leg
- C. Notify the physician
- D. Turn the client to the prone position
Correct Answer: A
Rationale: Applying direct pressure to a hematoma at the arteriogram site controls bleeding and prevents further complications, making it the initial action.