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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 is the highest priority due to potential for pneumothorax or mediastinal shift, which can be life-threatening. The ABC (airway, breathing, circulation) principle prioritizes this injury. Physiological Adaptation
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The patient is taking antidepressant drug, Elavil. The spouse of the patient complains that the dosage of the drug needs to be increased because no improvement is noted. The patient has been taking the drug for the last 3 days and no improvement is noted.
The most appropriate nursing response would be:
- A. I will inform the physician about your concern.
- B. It may take 3 to 4 weeks for the drug to work.
- C. The drug should work right away.
- D. Possible drug resistant has developed.
Correct Answer: B
Rationale: Elavil, a tricyclic antidepressant, typically takes 3–4 weeks to show therapeutic effects.
The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about energy conservation. Which of the following strategies should the nurse recommend?
- A. Perform all activities in the morning when energy is highest.
- B. Use a shower chair when bathing.
- C. Avoid using a pursed-lip breathing technique.
- D. Walk quickly to complete tasks efficiently.
Correct Answer: B
Rationale: Using a shower chair conserves energy by reducing exertion during bathing, a taxing activity for COPD patients. Morning activity (A) may not suit all, pursed-lip breathing (C) aids respiration, and quick walking (D) increases oxygen demand.
Marie is a 5-year-old girl is admitted with a diagnosis of Acute Lymphoblastic Leukemia.
Which of the following nursing interventions would be contraindicated to the patient with Leukemia?
- A. Take rectal temperature.
- B. Use soft toothbrush.
- C. Use normal saline for mouthwash TID.
- D. Avoid using dental floss.
Correct Answer: A
Rationale: Rectal temperatures risk rectal injury and infection in neutropenic patients.
The incidence of Sickle Cell Anemia is higher among black American babies.
The symptoms of sickle cell anemia are not evident until later during infancy because
- A. The baby is fed with milk formula, which is rich in ironbfb.
- B. The infant has a much higher RBC count than children and adult.
- C. Maternal iron is depleted later in infancy.
- D. Infants have more body fluids than any age group.
Correct Answer: C
Rationale: High levels of fetal hemoglobin prevent sickling of red blood cells. The newborn has from 44% to 89% fetal hemoglobin, but this rapidly decreases during the first year, making symptoms evident later.
Thirty minutes after delivery the nurse finds that a mother's uterus is relaxed and the lochia is excessive.
The fist action by the nurse should be to:
- A. Check the mother's vital signs.
- B. Elevate the foot part of the bed.
- C. Immediately notify the physician.
- D. Massage the mother's uterus and expel any clots.
Correct Answer: D
Rationale: Massaging the uterus promotes contraction, reducing excessive lochia and preventing hemorrhage.