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What is your priority intervention for this patient?
- A. Transportation arrangements to a safe house
- B. Referral to a counselor
- C. Advise about contacting the police
- D. Follow-up appointment for injuries
Correct Answer: A
Rationale: Ensuring the patient's safety by arranging transportation to a safe house is the top priority.
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In most states, directives to physicians, durable power of attorney for health care, and medical power of attorney are included in which legal documents?
- A. Natural death acts
- B. Allow natural death
- C. Advance care planning
- D. Do Not Resuscitate order.
Correct Answer: C
Rationale: Advance care planning encompasses various legal documents that outline a person's healthcare preferences and appoints proxies to make decisions on their behalf when incapacitated.
What observation would indicate the water-seal drainage system is working correctly?
- A. No bubbling of air in the suction control bottle
- B. Fluctuation of the fluid level in the tube of the water-seal bottle
- C. 25 ml of serosanguineous fluid has collected in the drainage bottle
- D. Excessive bubbling in the water-seal bottle
Correct Answer: B
Rationale: Fluctuation indicates proper lung expansion and absence of leaks.
A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?
- A. Increased respiratory rate from 18 to 44/min
- B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F)
- C. Increased blood pressure from 112/68 to 120/72 mm Hg
- D. Increased heart rate from 68 to 72/min
Correct Answer: A
Rationale: Step 1: Increased respiratory rate from 18 to 44/min indicates potential respiratory distress, a serious complication post-fracture.
Step 2: Rapid breathing can signify hypoxemia, pulmonary embolism, or infection, requiring immediate intervention.
Step 3: Increased oral temperature and blood pressure within normal range are not as critical as respiratory distress.
Step 4: A slight increase in heart rate is common after a fracture and not indicative of a serious complication.
A break in sterile technique occurs during surgery when the scrub nurse touches
- A. the mask with sterile gloved hands.
- B. sterile gloved hands to the gown at chest level.
- C. the drape at the incision site with sterile gloved hands.
- D. the lower arm to the instruments on the instrument tray.
Correct Answer: A
Rationale: Touching non-sterile items like masks compromises sterility and requires corrective action.
A male client has returned to the Unit following a left femoral popliteal bypass graft. Six hours later, the client's dorsalis pedis pulse cannot be palpated and his foot is cool and dusky. The nurse should:
- A. continue to monitor the foot.
- B. immediately notify the physician.
- C. notify the head nurse.
- D. assure the client that his foot is fine.
Correct Answer: B
Rationale: The client is losing the blood supply to his left foot. Continuing to monitor will not restore the blood supply to the foot. The physician should be notified immediately because the client is losing the blood supply to his left foot and is in danger of losing his foot and/or his leg. It is the responsibility of the nurse caring for the client to notify the physician, not the head nurse. This would be giving the client false assurances, which is unethical, demeaning, and could have legal consequences.