Nokea
Which of the following findings require follow up? Select all that apply.
- A. WBC count
- B. Temperature
- C. Potassium level
- D. Breath sounds
- E. Blood pressure
Correct Answer: A,B,D,E
Rationale: These findings suggest infection and respiratory distress, requiring immediate follow-up.
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After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next?
- A. Flush the catheter with saline
- B. Retract the stylet
- C. Advance the catheter into the vein
- D. Release the tourniquet
Correct Answer: C
Rationale: The correct answer is C: Advance the catheter into the vein. After confirming blood return in the flashback chamber, advancing the catheter ensures proper placement within the vein for medication delivery. Retracting the stylet (B) prematurely can displace the catheter. Flushing with saline (A) before confirming placement is risky. Releasing the tourniquet (D) is done after securing catheter placement.
Complete the following sentence by using the list of options. The client is at risk of----- as evidenced by-------
- A. fluid volume overload
- B. anemia
- C. hypostatic pneumonia
- D. calorie deficiency
- E. orthostatic hypotension
- F. immobility
Correct Answer: C,F
Rationale: Immobility increases the risk of hypostatic pneumonia, especially in clients with paraplegia.
A nurse in an emergency department is caring for a child who reports being sexually abused by a family member. Which of the following actions should the nurse take?
- A. Use leading statements to obtain information from the child
- B. Ensure that multiple nurses are present for the physical examination
- C. Explain to the child what will happen when the abuse is reported
- D. Reassure the child that no one will be told about the abuse
Correct Answer: C
Rationale: Correct Answer: C - Explain to the child what will happen when the abuse is reported.
Rationale: It is crucial for the nurse to inform the child about the reporting process to ensure transparency and build trust. This empowers the child and helps them understand the next steps. It also promotes their involvement in decision-making regarding their well-being. By explaining the process, the nurse can offer emotional support and reassurance to the child. This approach respects the child's autonomy and dignity.
Incorrect Choices:
A: Using leading statements can influence the child's responses and compromise the accuracy of information obtained.
B: Having multiple nurses present may intimidate the child and breach confidentiality.
D: Reassuring the child that no one will be told about the abuse may perpetuate feelings of isolation and hinder the necessary intervention.
Which of the following findings indicates that the child may be experiencing hemorrhage?
- A. Increased drowsiness
- B. Elevated pain level
- C. Diminished breath sounds
- D. Frequent swallowing
Correct Answer: D
Rationale: Frequent swallowing can indicate bleeding in the throat post-tonsillectomy.
The nurse should monitor the client for which of the following complications?
- A. Contractions
- B. Hypertension
- C. Epigastric pain
- D. Vomiting
Correct Answer: A
Rationale: Contractions can indicate preterm labor, a potential complication after amniocentesis.