Nokea
Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority?
- A. open leg fracture
- B. open head injury
- C. stab wound to the chest
- D. traumatic amputation of a thumb
Correct Answer: C
Rationale: A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of ABC (airway, breathing, and circulation) prioritizes care decisions.
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The HCP prescribes 5% albumin for four clients. The nurse should consult with the HCP if 5% albumin is prescribed for which client?
- A. The client of the Catholic faith who has refractory edema
- B. The African American client experiencing hypovolemic shock
- C. The client of the Jehovah's Witnesses faith who has cerebral edema
- D. The Asian client experiencing adult respiratory distress syndrome (ARDS)
Correct Answer: C
Rationale: A: Persons of the Catholic faith usually accept blood and blood products. B: Persons of African American ethnicity usually accept blood and blood products. C: Albumin is a blood derivative obtained by fractionating pooled venous and placental human plasma. Persons of the Jehovah's Witnesses faith usually do not accept RBCs; some do not accept blood products such as albumin or plasma. D: Persons of Asian ethnicity usually accept blood and blood products.
The nurse is educating the client concerning the possible side effects of a newly prescribed traditional antipsychotic medication. Which client statement reflects a need for further education regarding the side effects of this classification of medication?
- A. I need to get up from bed slowly so I will not get dizzy.
- B. The medication can cause constipation, so I need to eat fiber.
- C. I may need a sleeping pill because insomnia is a possible side effect.
- D. I can't risk gaining weight, so I will need to add some exercise to my routine.
Correct Answer: C
Rationale: Drowsiness, not insomnia, is a common side effect of traditional antipsychotics, indicating a need for further teaching.
Oral terbutaline is prescribed for the client with bronchitis. Which comorbidity most warrants the nurse's close monitoring of the client following administration of terbutaline?
- A. Strabismus
- B. Hypertension
- C. Diabetes insipidus
- D. Hypothyroidism
Correct Answer: B
Rationale: A: Terbutaline should be used with caution in clients with glaucoma (not strabismus). B: The client's history of hypertension warrants the nurse's close monitoring of the client when terbutaline (Brethine) is administered. It should be used with caution in clients with hypertension because it can precipitate a hypertensive episode. C: Terbutaline should be used with caution in clients with DM (not DI). D: Terbutaline should be used with caution in clients with hyperthyroidism (not hypothyroidism).
Melissa Smith came to the Emergency Department in the last week before her estimated date of confinement complaining of headaches, blurred vision, and vomiting. Suspecting PIH, the nurse should best respond to Melissa's complaints with which of the following statements?
- A. The physician will probably want to admit you for observation.'
- B. The physician will probably order bed rest at home.'
- C. These are really dangerous signs.'
- D. The physician will probably prescribe some medicine for you.'
Correct Answer: B
Rationale: Pregnancy-induced hypertension (PIH) symptoms like headaches, blurred vision, and vomiting suggest preeclampsia, which is best managed with bed rest at home unless severe, requiring hospitalization.
The hospitalized client is prescribed to receive ferrous fumarate 200 mg oral daily. When transcribing the medication onto the client's MAR, at which time in military time should the nurse schedule the daily dose for best absorption?
- A. 830
- B. 1000
- C. 1230
- D. 1730
Correct Answer: B
Rationale: A: 0830 is near the time of breakfast in a health care facility. Food reduces the absorption of iron. B: For best absorption and therapeutic effectiveness, the nurse should schedule ferrous fumarate (Feosol) at 1000. Iron preparations should be administered one hour before or two hours after a meal because food diminishes iron absorption. C: 1230 is near lunchtime in a health care facility. Food reduces the absorption of iron. D: 1730 is near the evening meal in a health care facility. Food reduces the absorption of iron.