Nokea
When reassigned to the emergency department, a nurse should understand that gastric lavage is a priority in which situation?
- A. An infant who has been identified to have botulism
- B. A toddler who ate a number of ibuprofen tablets
- C. A preschooler who swallowed powdered plant food
- D. A school-aged child who took a handful of vitamins
Correct Answer: A
Rationale: The correct answer is A because gastric lavage is a priority for infants with botulism to remove toxins from the stomach. Botulism is a serious condition caused by a toxin produced by Clostridium botulinum bacteria. Gastric lavage helps in removing the toxin from the stomach. Choice B is incorrect because gastric lavage is not typically indicated for ibuprofen ingestion. Choice C is incorrect because gastric lavage is not the first-line treatment for ingesting powdered plant food. Choice D is incorrect because gastric lavage is not routinely performed for vitamin ingestion.
You may also like to solve these questions
The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to
- A. Wrap the leg with elastic bandages
- B. Apply pressure at the bleeding site
- C. Reinforce the dressing and elevate the leg
- D. Remove the dressings and re-dress the incision
Correct Answer: B
Rationale: In this scenario where the upper leg dressing becomes saturated with blood post-femoral popliteal bypass, the nurse's first action should be to apply pressure at the bleeding site. Applying pressure is essential to control hemorrhage and prevent further blood loss.
Choice A is incorrect as wrapping the leg with elastic bandages would not address the immediate issue of controlling the bleeding.
Choice C is incorrect because reinforcing the dressing and elevating the leg should come after controlling the bleeding.
Choice D is incorrect as removing the dressings and re-dressing the incision should only be done after the bleeding is under control to prevent excessive blood loss.
A client who is 2 days postoperative following abdominal surgery is transitioning from a clear liquid diet to a full liquid diet. The nurse should remind the client that which of the following items is included in a full liquid diet?
- A. Creamed peas
- B. Cottage cheese
- C. Chocolate pudding
- D. Applesauce
Correct Answer: C
Rationale: The correct answer is C, chocolate pudding. A full liquid diet consists of smooth, creamy foods like pudding. Creamed peas (choice A) are not typically allowed on a full liquid diet as they may contain solid pieces. Cottage cheese (choice B) and applesauce (choice D) are also not part of a full liquid diet as they are not in liquid form.
A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is:
- A. difference in the intake and output
- B. changes in the mucous membranes
- C. skin turgor
- D. weekly weight
Correct Answer: D
Rationale: In a client with altered renal function, monitoring fluid balance is crucial. Weekly weight is the most accurate indicator of fluid balance during the visits as it reflects cumulative changes in the body's fluid status. Changes in intake and output (Choice A) can provide valuable information, but weekly weight is a more direct measure of overall fluid retention or loss. Changes in mucous membranes (Choice B) and skin turgor (Choice C) can be influenced by factors other than fluid balance, making them less reliable indicators in this context.
A client is receiving intravenous antibiotics for the treatment of a severe infection. Which of these assessments is a priority for the nurse to perform?
- A. Monitor the client's temperature
- B. Assess the client's pain level
- C. Check the intravenous (IV) site for signs of phlebitis
- D. Monitor the client's respiratory status
Correct Answer: C
Rationale: When a client is receiving intravenous antibiotics, checking the IV site for signs of phlebitis is a priority assessment for the nurse. Phlebitis is an inflammation of the vein, which can lead to serious complications such as infection and thrombosis. Monitoring the IV site helps prevent these complications and ensures the safe delivery of antibiotics. While monitoring the client's temperature, pain level, and respiratory status are important assessments, they are not the priority in this scenario where IV antibiotic administration requires close monitoring for complications like phlebitis.
While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response?
- A. As you urinate more, you will need less medication to control fluid.
- B. You will have to take this medication for about a year.
- C. The medication must be continued so the fluid problem is controlled.
- D. Please talk to your health care provider about medications and treatments.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.