Which of the following tasks is most appropriate to delegate to the nursing assistant?
- A. Escort the family to a place of privacy
- B. Go with the organ donor specialist to talk to the family
- C. Assist with postmortem care
- D. Assist the family to collect belongings
Correct Answer: C
Rationale: Postmortem care involves basic hygiene and positioning, which can be performed by a nursing assistant.
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A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For
which of the following client findings should the nurse intervene first?
- A. Urticaria
- B. Stridor
- C. Vomiting
- D. Hypotension
Correct Answer: B
Rationale: The correct answer is B: Stridor. Stridor is a high-pitched, inspiratory sound that indicates upper airway obstruction and impending respiratory distress, which is a life-threatening complication of anaphylaxis. The nurse should intervene first by ensuring a patent airway to prevent respiratory compromise. Urticaria (A) is a common symptom of an allergic reaction but does not pose an immediate threat to airway patency. Vomiting (C) can be a sign of gastrointestinal distress but does not require immediate intervention for airway protection. Hypotension (D) is a serious manifestation of anaphylaxis but addressing airway obstruction takes precedence to prevent respiratory failure.
A 72-year-old female client is lifted to the surgery table in preparation for a total knee replacement. The client is in stage III of inhalation anesthesia. An appropriate nursing action for this client is:
- A. to prevent injury by assisting the anesthesiologist to restrain the client, if necessary.
- B. to prepare the operative site.
- C. to promote restoration of ventilation and vasomotor tone.
- D. to reduce external stimuli.
Correct Answer: B
Rationale: Preventing injury by restraining the client, if necessary, is a nursing action of stage II, which extends from loss of consciousness to relaxation. Stage III extends from the loss of lid reflex to cessation of voluntary respirations. Operative procedures are performed during stage III of inhalation anesthesia. Promoting restoration of ventilation and vasomotor tone is a nursing action for stage IV in which an overdose has occurred. Respiratory arrest and vasomotor collapse result from medullary paralysis. Reduction of external stimuli is a nursing action for stage I, which extends from induction to loss of consciousness.
You are taking histories from several clients who report vertigo. Which client report concerns you the most?
- A. Vertigo with hearing loss
- B. Episodic vertigo
- C. Vertigo without hearing loss
- D. Merry-go-round' vertigo
Correct Answer: A
Rationale: Vertigo accompanied by hearing loss may indicate Meniere's disease or other serious inner ear disorders requiring prompt evaluation.
What assessment data will the nurse gather when caring for a client with anxiety?
- A. High blood pressure
- B. Increased heart rate
- C. Decreased oxygen supply
- D. Muscle relaxation
Correct Answer: B
Rationale: The correct answer is B because it is the most appropriate response based on physiological and medical principles.
Sue is diagnosed with congestive heart failure. What medication would you expect to administer to strengthen myocardial contractility?
- A. Nitroprusside.
- B. Digoxin.
- C. Nitroglycerine ointment.
- D. Furosemide.
Correct Answer: B
Rationale: Digoxin enhances myocardial contractility in CHF.