Nokea
To approach a deaf client, the nurse should do which of the following first?
- A. Knock on the room's door loudly.
- B. Close and open the vertical blinds rapidly.
- C. Talk while walking into the room.
- D. Get the client's attention.
Correct Answer: D
Rationale: Getting the client's attention first (e.g., by waving or tapping gently) ensures effective communication with a deaf client, as they may not hear auditory cues.
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Which of the following activities should the nurse teach the client to implement after the removal of nasal packing on the second postoperative day?
- A. Avoid cleaning the nares until swelling has subsided.
- B. Apply water-soluble jelly to lubricate the nares.
- C. Keep a nasal drip pad in place to absorb secretions.
- D. Use a bulb syringe to gently irrigate nares.
Correct Answer: B
Rationale: Applying water-soluble jelly lubricates the nares, preventing crusting and discomfort post-packing removal. Cleaning is safe once packing is removed. A drip pad is unnecessary unless bleeding persists. Irrigation with a bulb syringe is not standard care.
An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which is normal should be placed on the tag? Select all that apply.
- A. Triage priority.
- B. Identifying information when possible (such as name, age, and address).
- C. Medications and treatments administered.
- D. Presence of jewelry.
- E. Next of kin.
Correct Answer: A,B,C
Rationale: Victim tags should include triage priority, identifying information, and treatments administered to ensure proper care and identification. Jewelry and next of kin are secondary considerations.
A client with a spinal cord injury is at risk for pressure ulcers. Which nursing intervention is most effective?
- A. Reposition the client every 4 hours.
- B. Use a foam mattress without a cover.
- C. Apply lotion to bony prominences daily.
- D. Turn the client every 2 hours.
Correct Answer: D
Rationale: Turning every 2 hours redistributes pressure, preventing ulcer formation in immobilized clients.
A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial line is inserted. Which of the following orders should the nurse question?
- A. Call for urine output <30 mL/hour for 2 consecutive hours.
- B. Metoprolol (Lopressor) 5 mg I.V. push.
- C. Symptom for a pulmonary artery catheter insertion.
- D. Titrate Dobutamine (Dobutrex) to keep systolic BP >100.
Correct Answer: B
Rationale: Metoprolol, a beta-blocker, can worsen cardiogenic shock by reducing heart rate and contractility. Other orders are appropriate for monitoring and supporting perfusion in cardiogenic shock.
A client post-extracorporeal shock wave lithotripsy should report:
- A. Mild hematuria.
- B. Severe flank pain.
- C. Clear urine.
- D. Bruising.
Correct Answer: B
Rationale: Severe flank pain may indicate a complication like hematoma or obstruction.