Nokea
Triage refers to the classification of injury severity during a disaster. Which of the following clients should receive priority during triage?
- A. Open fractures of the tibia and fibula
- B. Burns of the head and neck
- C. Crushing injury of the arm
- D. Contusions and lacerations of the head without loss of consciousness
Correct Answer: B
Rationale: Burns to the head and neck are prioritized due to potential airway compromise, a life-threatening condition. Open fractures, crushing injuries, and minor head injuries are less immediately critical.
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A client is being discharged following insertion of a permanent set pacemaker. A client with a permanent set pacemaker should be taught:
- A. To keep a loose dressing over the insertion site at all times
- B. That the pacemaker will function continuously at a set rate
- C. That increases in activity will require adjustments in the pacemaker setting
- D. That he will have to modify his lifestyle to allow for afternoon rest periods
Correct Answer: C
Rationale: Modern pacemakers adjust their rate based on activity (rate-responsive pacing), so the client should understand that increased activity may require pacemaker adjustments.
A nurse is working in an outpatient orthopedic clinic. During the patient's history the patient reports, 'I tore 3 of my 4 Rotator cuff muscles in the past.' Which of the following muscles cannot be considered as possibly being torn?
- A. Teres minor
- B. Teres major
- C. Supraspinatus
- D. Infraspinatus
Correct Answer: B
Rationale: Teres Minor, Infraspinatus, Supraspinatus, and Subscapularis make up the Rotator Cuff.
A client with right-sided weakness.
The nurse in the outpatient clinic teaches a client with right-sided weakness to walk down stairs using a cane. What behavior, if demonstrated by the client, would indicate that teaching was successful?
- A. The client puts her right leg on the step, then the cane, followed by her left leg.
- B. The client leads with the cane, followed by her right leg, and then her left leg.
- C. The client advances her right leg, followed by her left leg and the cane.
- D. The client puts the cane on the step and advances her left leg, followed by her right leg.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) to go down stairs, advance weak leg and cane first; to go up stairs, advance strong leg, then weak leg and cane (2) correct-to do down stairs, advance cane and weak leg, then strong leg; memory trick: the good goes up, the bad goes down (3) should advance cane and weak leg first (4) weaker leg and cane advance first
A 25-year-old woman after a vaginal delivery.
Which of the following is the FIRST nursing action that should be implemented for a 25-year-old woman after a vaginal delivery?
- A. Check the patient's lochial flow.
- B. Palpate the patient's fundus.
- C. Monitor the patient's pain.
- D. Assess the patient's level of consciousness.
Correct Answer: A
Rationale: Strategy: 'FIRST' indicates that this is a priority question. Remember the ABCs. (1) correct-complication of hemorrhage assessed by observing lochial flow (2) done to assist its natural clamping-down action, assessed as firm or boggy (3) must meet physical needs first (4) not first action, hemorrhage most important complication
A client after a bronchoscopy.
The nurse would be MOST concerned if which of the following was observed?
- A. Depressed gag reflex.
- B. Sputum streaked with blood.
- C. Tachypnea.
- D. Complaints of a sore throat.
Correct Answer: C
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) would cause a complication if client is given fluids before the gag reflex has returned (2) common for a few days after a biopsy (3) correct-client should be assessed for symptoms of respiratory distress from swelling due to the procedure; signs of respiratory distress include tachypnea, tachycardia, respiratory stridor, and retractions (4) expected after this procedure