Nokea
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.
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The client is admitted to the ER with multiple rib fractures on the right. The nurse's assessment reveals that an area over the right clavicle is puffy and that there is a 'crackling' noise with palpation. The nurse should further assess the client for which of the following problems?
- A. Flail chest
- B. Subcutaneous emphysema
- C. Infiltrated subclavian IV
- D. Pneumothorax
Correct Answer: B
Rationale: The 'puffy' area and 'crackling' noise (crepitus) with palpation are classic signs of subcutaneous emphysema, where air is trapped under the skin, often due to a pneumothorax or rib fractures allowing air to escape into subcutaneous tissue.
The doctor has prescribed Claratin (loratidine) for a client with seasonal allergies. The feature that separates Claratin from other antihistamines such as diphenhydramine is that the medication:
- A. Is nonsedating
- B. Stimulates appetite
- C. Is used for motion sickness
- D. Is less expensive
Correct Answer: A
Rationale: Loratadine (Claritin) is a second-generation antihistamine that is nonsedating, unlike first-generation antihistamines like diphenhydramine.
According to Maslow's hierarchy of needs, 'lack of prejudice' falls under which level of human need fulfillment?
- A. love and belonging
- B. self-actualization
- C. safety
- D. esteem
Correct Answer: B
Rationale: Lack of prejudice reflects self-actualization, Maslow’s highest level, where individuals achieve personal growth and acceptance of others.
Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis?
- A. Brushing the teeth
- B. Drinking a glass of juice
- C. Holding a cup of coffee
- D. Brushing the hair
Correct Answer: C
Rationale: Holding a warm cup of coffee can reduce morning stiffness in rheumatoid arthritis by providing warmth and gentle joint movement.
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.