Nokea
Which of these clients would the triage nurse request the provider examine immediately?
- A. A 5 month-old infant who has audible wheezing and grunting
- B. An adolescent who has soot over the face and shirt
- C. A middle-aged man with second degree burns over the right hand
- D. A toddler with singed ends of long hair that extends to the waist
Correct Answer: A
Rationale: A 5 month-old infant who has audible wheezing and grunting. The age and the findings suggest this client is at immediate risk for respiratory complications.
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The nurse is caring for a client with a history of heart failure who is receiving furosemide (Lasix) 40 mg PO daily. Which of the following laboratory results should the nurse report immediately?
- A. Potassium 3.0 mEq/L.
- B. Sodium 140 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Glucose 100 mg/dL.
Correct Answer: A
Rationale: Hypokalemia (3.0 mEq/L) from furosemide increases arrhythmia risk in heart failure. Options B, C, and D are normal.
The nurse is caring for a client with a history of atrial fibrillation who is receiving warfarin (Coumadin) 5 mg PO daily. Which of the following laboratory results should the nurse report immediately?
- A. INR of 3.5.
- B. PTT of 40 seconds.
- C. Platelet count of 200,000/mm^3.
- D. Hemoglobin of 13 g/dL.
Correct Answer: A
Rationale: An INR of 3.5 is above the therapeutic range (2.0–3.0), increasing bleeding risk. Options B, C, and D are normal.
The nurse is caring for a client who has a cervical radioactive implant. Which action is not appropriate for the nurse when caring for this client?
- A. Post a radioactive symbol on the client's chart and on the door to the room.
- B. Put on gloves to remove any radioactive implant that may have come out.
- C. Wash hands with soap and water after caring for the client.
- D. Limit the amount of time with the client.
Correct Answer: B
Rationale: Removing a radioactive implant requires specialized handling, not just gloves, to avoid exposure, making this action inappropriate.
Which statement made by an adolescent indicates understanding of how to reduce risk of osteoporosis later in life?
- A. I will be careful not to sprain my ankle when I play sports.'
- B. I drink a glass of milk with every meal.'
- C. As I get older, I will reduce the amount of weight-bearing exercise I do.'
- D. My favorite beverages are cola drinks.'
Correct Answer: B
Rationale: High calcium intake (milk) builds bone density, reducing osteoporosis risk. Sprains, reduced exercise, or cola drinks don't address bone health.
The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?
- A. Irritability
- B. Slight edema at site
- C. Local tenderness
- D. Seizure activity
Correct Answer: D
Rationale: Seizure activity. Other reactions that should be reported include crying for >3 hours, temperature over 104.8 degrees Fahrenheit following DPT immunization, and tender, swollen, reddened areas.