Nokea
A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion.
Which of the following actions should the nurse plan to take?
- A. Keep calcium gluconate at the client's bedside
- B. Monitor blood pressure every 2 hr.
- C. Protect IV bag from exposure to light.
- D. Attach an inline filter to the IV tubing.
Correct Answer: C
Rationale: The correct answer is C: Protect IV bag from exposure to light. This is important because certain medications in IV bags can degrade when exposed to light, leading to reduced efficacy or potential harm to the patient. Keeping the IV bag protected helps maintain the integrity of the medication.
Choice A is incorrect because calcium gluconate should be stored properly but doesn't necessarily need to be kept at the bedside at all times.
Choice B is incorrect as monitoring blood pressure every 2 hours may not be necessary for all patients and is not specific to the scenario given.
Choice D is incorrect as attaching an inline filter to the IV tubing may be necessary in certain situations but is not the most relevant action based on the information provided.
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A nurse is obtaining the temperature of a newborn.
Which of the following sites should the nurse use?
- A. Axillary
- B. Rectal
- C. Oral
- D. Tympanic
Correct Answer: B
Rationale: The nurse should use the rectal site for temperature measurement as it provides the most accurate core body temperature reading. Rectal temperature closely reflects internal body temperature, making it the preferred site for assessing critically ill patients or infants who cannot cooperate for oral measurements. Axillary, oral, and tympanic sites may not accurately represent core body temperature due to external factors affecting the readings. Rectal temperature is the gold standard for accurate temperature measurement in certain clinical situations.
A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets a respiratory rate of 10/min.
After securing the client's airway and initiating an IV, which of the following actions should the nurse do next.
- A. Administer flumazenil to the client.
- B. Initiate gastric lavage with activated charcoal.
- C. Place the client in the Trendelenburg position.
- D. Obtain a stat CT scan of the brain.
Correct Answer: A
Rationale: The correct answer is A: Administer flumazenil to the client. Flumazenil is a specific benzodiazepine receptor antagonist used to reverse the effects of benzodiazepine overdose, which includes respiratory depression. Administering flumazenil would help reverse the sedative effects of benzodiazepines and improve the client's respiratory status. Initiating gastric lavage with activated charcoal (B) is not the immediate priority after securing the airway and IV. Placing the client in the Trendelenburg position (C) is not recommended due to potential complications. Obtaining a stat CT scan of the brain (D) is not necessary at this point and does not address the immediate concerns of airway and sedation reversal.
A nurse in the emergency department is caring for a client who is actively bleeding from a stab wound to the thigh.
Which action should the nurse take?
- A. Apply direct pressure to the wound with thick dressing material.
- B. Elevate the affected leg above heart level and apply light dressing.
- C. Apply a tourniquet immediately above the wound site.
- D. Apply ice packs to the wound to slow the bleeding.
Correct Answer: A
Rationale: The correct answer is A. Applying direct pressure to the wound with thick dressing material is the most appropriate action to control bleeding. It helps to compress the blood vessels, slowing down the bleeding. Elevating the leg (choice B) may not be enough to stop severe bleeding. Applying a tourniquet (choice C) should only be done as a last resort for life-threatening bleeding as it can lead to tissue damage. Applying ice packs (choice D) constricts blood vessels, potentially trapping harmful substances in the wound. It is crucial to address the immediate bleeding before considering other actions.
A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider?
- A. Dyspnea
- B. Pain at the surgical site
- C. Mild nausea
- D. Temperature of 37.5°C (99.5°F)
Correct Answer: A
Rationale: The correct answer is A: Dyspnea. Dyspnea in a postoperative client with a history of pulmonary embolism indicates a potential complication, such as a recurrent or new pulmonary embolism, which can be life-threatening. The nurse should report this finding to the provider immediately for further evaluation and intervention to prevent worsening respiratory distress and potential respiratory failure. Pain at the surgical site (choice B) is expected postoperatively and can be managed with appropriate pain medications. Mild nausea (choice C) is a common postoperative symptom and can be managed with antiemetic medications. A temperature of 37.5°C (99.5°F) (choice D) may indicate a mild fever, which can be monitored unless accompanied by other concerning symptoms.
An occupational health nurse is providing teaching to a group of factory workers about proper lifting techniques.
Which statement should the nurse make?
- A. Bend at the waist when lifting objects from the floor.
- B. Keep the object close to your body when lifting.
- C. Twist your torso while lifting to maintain balance.
- D. Lift heavy objects quickly to reduce strain on the muscles.
Correct Answer: B
Rationale: The correct answer is B: Keep the object close to your body when lifting. This statement is correct because keeping the object close to the body reduces the strain on the back muscles and promotes proper lifting mechanics. By keeping the object close, the center of gravity is maintained, reducing the risk of injury.
Incorrect answers:
A: Bending at the waist when lifting can strain the lower back.
C: Twisting the torso while lifting can lead to back injuries.
D: Lifting heavy objects quickly can increase the risk of muscle strains and injuries.