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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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A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
- A. Insert an indwelling urinary catheter.
- B. Inspect the mouth for signs of inhalation injuries.
- C. Administer intravenous pain medication.
- D. Draw blood for a complete blood cell (CBC) count.
Correct Answer: B
Rationale: The correct answer is B: Inspect the mouth for signs of inhalation injuries. This is the priority action because inhalation injuries can be life-threatening due to airway compromise. The nurse should assess for soot in the mouth, facial burns, hoarseness, and difficulty breathing. This allows for prompt intervention if respiratory distress is present.
A: Inserting an indwelling urinary catheter is not the priority as it does not address the immediate life-threatening issue.
C: Administering pain medication is important but not the priority over assessing for inhalation injuries which could lead to respiratory distress.
D: Drawing blood for a CBC count is not the priority as it does not address the immediate threat to the client's airway.
Which of the following describes a 'comfort zone'?
- A. The area where closeness is not required during nursing care.
- B. The area that encompasses up to 5 to 7 feet from the client.
- C. The area that,when intruded upon does not create any kind of anxiety.
- D. The area where a client is well draped.
Correct Answer: B
Rationale: A comfort zone typically refers to the personal space around an individual, which varies but generally extends up to 5-7 feet.
Why is it important for a nurse to move a victim of a common respiratory toxin to higher ground immediately?
- A. The toxins flow to the lower ground.
- B. The toxic vapors stay close to the ground.
- C. The toxins are always released close to the ground.
- D. The heavy and the solid toxins cannot move to a height.
Correct Answer: B
Rationale: The correct answer is B because many respiratory toxins are heavier than air and settle near the ground.
A nursing department in an acute care setting decides to redesign its nursing practice based on a theoretical framework. The feedback from patients, families, and staff reflects that caring is a key element. Which theorist best supports this concept?
- A. Erikson.
- B. Maslow.
- C. Rogers.
- D. Watson.
Correct Answer: D
Rationale: Jean Watson's theory emphasizes the importance of caring in nursing.
For a client who has sustained recent blindness, which task(s) would be appropriate to delegate to the nursing assistant? (Choose all that apply.)
- A. Listen to the client express grief or loss.
- B. Assist client to ambulate in hall.
- C. Orient client to surroundings.
- D. Encourage independence.
Correct Answer: B
Rationale: Assisting with mobility is within the scope of practice for nursing assistants and ensures safety for the client.