Nokea
What should the nurse admitting the child with autism do about the room assignment?
- A. Request that the child be transferred to a private room.
- B. Request that the child be transferred to a double room.
- C. Admit the child to the room that has been preassigned.
- D. Request that the child be assigned to an isolation room.
Correct Answer: A
Rationale: A private room is preferred for a child with autism to minimize sensory overload and ensure a calm environment.
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The HCP prescribes cyclobenzaprine 30 mg orally tid for the client hospitalized with acute cervical neck pain. The pharmacy supplied 10-mg tablets. Which action by the nurse is best?
- A. Administer three 10-mg tablets with food
- B. Call the HCP to question the dose prescribed
- C. Observe for drowsiness after administration
- D. Also give prn prescribed morphine sulfate IV
Correct Answer: B
Rationale: B. The nurse should call the HCP to question the dose. If carried out as prescribed, the client would receive a total daily dose of 90 mg of cyclobenzaprine (Flexeril). The total daily dose should not exceed 60 mg.
The client is taken to the emergency department with an injury to the left arm. Which intervention should the nurse implement first?
- A. Assess the nailbeds for capillary refill time.
- B. Remove the client's clothing from the arm.
- C. Call radiology for a STAT x-ray of the extremity.
- D. Prepare the client for the application of a cast.
Correct Answer: A
Rationale: Assessing capillary refill evaluates neurovascular status, the priority in arm injury to detect compromise. Clothing removal, x-rays, and casting follow assessment.
A person's right thumb was accidentally severed with an axe. The amputated right thumb was recovered. Which action by the nurse preserves the thumb so it could possibly be reattached in surgery?
- A. Place the right thumb directly on ice.
- B. Put the right thumb in a glass of warm water.
- C. Wrap the thumb in a clean piece of material.
- D. Secure the thumb in a plastic bag and place on ice.
Correct Answer: D
Rationale: Wrapping the thumb and placing it in a bag on ice preserves viability for reattachment without freezing tissue. Direct ice causes frostbite, warm water promotes decay, and wrapping alone is insufficient.
Which material added by the nurse is best for covering the tips of the pin to prevent injuries while the client is in skeletal leg.
- A. Gauze squares
- B. Cotton balls
- C. Cork blocks
- D. Rubber tubes
Correct Answer: C
Rationale: Cork blocks securely cover pin tips, preventing injury to the client or staff while maintaining stability. Gauze and cotton are less durable, and rubber tubes may not fit securely.
Which statement by the client diagnosed with a fractured ulna indicates to the nurse the client needs further teaching?
- A. I need to eat a high-protein diet to ensure healing.'
- B. I need to wiggle my fingers every hour to increase circulation.'
- C. I need to take my pain medication before my pain is too bad.'
- D. I need to keep this immobilizer on when lying down only.'
Correct Answer: D
Rationale: Immobilizers must be worn continuously to stabilize a fractured ulna, not just when lying down. High-protein diet, finger movement, and proactive pain management are correct.