Nokea
What type of contamination is the nurse trying to eliminate when he or she requests people to remove all garments before entering a house or shelter?
- A. Internal radiologic contamination
- B. External vesicant contamination
- C. External radioactive contamination
- D. Cross-contamination
Correct Answer: C
Rationale: The correct answer is C because removing contaminated clothing reduces external radioactive exposure.
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The charge nurse assigned the care of a client with acute renal failure and hypernatremia to you, a newly graduated RN. Which actions can you delegate to the nursing assistant? (Choose all that apply.)
- A. Provide oral care every 3-4 hours
- B. Monitor for indications of dehydration
- C. Administer 0.45% saline by IV line
- D. Assess daily weights for trends
Correct Answer: A
Rationale: Oral care and assessing daily weights are tasks that can be delegated to a nursing assistant. Monitoring for dehydration and administering IV fluids require more advanced clinical skills.
What nursing measure would be most helpful in soliciting Mr. Ross’s cooperation with arm and shoulder exercises?
- A. Inform Mr. Ross that these exercises must be done before each meal and at bedtime
- B. Give Mr. Ross a booklet which diagrams the exercises
- C. Teach Mrs. Ross how to do these exercises
- D. Ask Mr. Ross which times are most convenient for him to exercise
Correct Answer: D
Rationale: Tailoring exercise schedules to patient preferences enhances adherence.
Following a cocaine high, the user commonly experiences an extremely unpleasant feeling called:
- A. Craving.
- B. Crashing.
- C. Outward bound.
- D. Nodding out.
Correct Answer: B
Rationale: Crashing refers to the intense fatigue and depression following cocaine use.
The trauma unit nurse has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?
- A. Evaluate chest expansion.
- B. Check pupillary response to light.
- C. Assess the capillary refill.
- D. Check the client's response to questions about place and time.
Correct Answer: A
Rationale: The correct answer is A: Evaluate chest expansion. This is the priority action because it assesses the client's airway and breathing, which are critical for survival. Checking chest expansion helps to identify any potential respiratory compromise or underlying lung injuries. Assessing pupillary response (B) and capillary refill (C) are important, but they are secondary to ensuring adequate oxygenation. Checking the client's orientation to place and time (D) is important for neurological assessment but is not as critical as assessing airway and breathing in this scenario.
Karen is suspected of having a hormone imbalance. What would you expect to monitor
- A. Electrolyte levels.
- B. Thyroid studies, follicle-stimulating hormone (FSH), and luteinizing hormone (LH).
- C. Caloric intake.
- D. All of the above.
Correct Answer: D
Rationale: Hormonal imbalances affect multiple systems and require comprehensive monitoring.