Nokea
The parent of a 6-year-old calls the nurse and reports that the child was playing outside in the snow and the child's feet now appear red and swollen. What is the best response by the nurse?
- A. Bring the child to the health care provider's (HCP) office immediately.
- B. Give your child something warm to drink.
- C. Massage the child's feet gently until they warm up.
- D. Place the child's feet in warm water immediately.
Correct Answer: D
Rationale: Red and swollen feet suggest frostbite or cold injury. Immersing the feet in warm (not hot) water is the safest and most effective way to rewarm the tissue and prevent further damage.
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The nurse is collecting data from a client with heart failure. The nurse notes that the client is agitated, has crackles bilaterally, and is reporting dyspnea and anxiety. The nurse should place the client in
- A. modified Trendelenburg position
- B. high Fowler position
- C. left Sims position
- D. supine position
Correct Answer: B
Rationale: High Fowler position optimizes lung expansion and reduces preload, alleviating dyspnea and crackles in acute heart failure exacerbation.
The nurse assesses a child with intussusception. Which assessment findings require priority intervention?
- A. Abdominal rigidity with guarding
- B. Absence of tears in crying child with IV start
- C. Blood-streaked mucous stool in diaper
- D. Sausage-shaped right-sided mass on palpation
Correct Answer: A
Rationale: Abdominal rigidity with guarding suggests peritonitis or perforation, critical complications of intussusception requiring immediate surgical intervention.
The client is admitted with hypokalemia. An IV of normal saline is infusing at $80 \mathrm{ml} /$ hour with 10 meq of $\mathrm{KCl} /$ hour. Prior to beginning the infusion, the nurse should:
- A. Check the sodium level.
- B. Check the magnesium level.
- C. Check the creatinine level.
- D. Check the calcium level.
Correct Answer: B
Rationale: Hypokalemia is often associated with hypomagnesemia, which can impair potassium correction. Checking the magnesium level ensures effective treatment. Sodium , creatinine , and calcium levels are less directly related to potassium infusion safety.
A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to
- A. A social worker from the local hospital
- B. A physical therapist to improve fine motor coordination
- C. An activity therapist from the community center
- D. Another client with diabetes mellitus and takes insulin
Correct Answer: B
Rationale: A physical therapist can assist a client to improve the fine motor skills needed to prepare an insulin injection.
The nurse is preparing to assist a client to ambulate to the bathroom. The client rises from the chair at the bedside and immediately reports feeling dizzy. It would be a priority for the nurse to
- A. Check the client's orthostatic blood pressure
- B. encourage the client to remain on bed rest
- C. apply a gait belt around the client's waist
- D. assist the client back to a sitting position
Correct Answer: D
Rationale: Dizziness upon standing suggests orthostatic hypotension or other instability. Assisting the client back to a sitting position prevents falls and ensures immediate safety.