Nokea
Which problem is most appropriate for the nurse to identify for the client experiencing renal trauma?
- A. Infection of the renal tract.
- B. Ineffective tissue perfusion.
- C. Alteration in skin integrity.
- D. Alteration in temperature.
Correct Answer: B
Rationale: Renal trauma risks bleeding and hypoperfusion, making ineffective tissue perfusion the primary problem. Infection, skin integrity, and temperature are less immediate.
You may also like to solve these questions
A vat of chemicals spilled onto the client. Which action should the occupational health nurse implement first?
- A. Have the client stand under a shower while removing all clothes.
- B. Check the material safety data sheets for the antidote.
- C. Administer oxygen by nasal cannula.
- D. Collect a sample of the chemicals in the vat for analysis.
Correct Answer: A
Rationale: Removing clothes and showering decontaminates the skin, preventing further chemical absorption. MSDS, oxygen, and sampling are secondary.
Which statement explains the scientific rationale for having emergency suction equipment available during resuscitation efforts?
- A. Gastric distention can occur as a result of ventilation.
- B. It is needed to assist when intubating the client.
- C. This equipment will ensure a patent airway.
- D. It keeps the vomitus away from the healthcare provider.
Correct Answer: C
Rationale: Suction equipment clears vomit or secretions, ensuring a patent airway during resuscitation. Gastric distention, intubation, and HCP protection are secondary concerns.
A gang war has resulted in 12 young males being brought to the emergency department. Which action by the nurse is priority when a gang member points a gun at a rival gang member in the trauma room?
- A. Attempt to talk to the person who has the gun.
- B. Explain to the person the police are coming.
- C. Stand between the client and the man with the gun.
- D. Get out of the line of fire and protect self.
Correct Answer: D
Rationale: Self-protection by exiting the line of fire prioritizes nurse safety, allowing for security intervention. Talking, explaining police arrival, or standing between risks harm.
The client in a code is now in ventricular bigeminy. The HCP orders a lidocaine drip at three (3) mg/min. The lidocaine comes prepackaged with two (2) grams of lidocaine in 500 mL of D5W. At which rate will the nurse set the infusion pump?
Correct Answer: 45
Rationale: Lidocaine concentration: 2 g = 2000 mg in 500 mL = 4 mg/mL. Dose: 3 mg/min. Rate = (3 mg/min) / (4 mg/mL) = 0.75 mL/min = 45 mL/hour (0.75 * 60). Pump set to 45 mL/hour.
The charge nurse is making assignments. Which client should be assigned to the most experienced nurse?
- A. The client diagnosed with a snake bite who is receiving antivenin.
- B. The client who swallowed a lye preparation and is being discharged.
- C. The client who is angry the suicide attempt did not work.
- D. The client who required skin grafting after a chemical spill.
Correct Answer: A
Rationale: Antivenin administration for snake bites requires close monitoring for anaphylaxis and dosing, best handled by an experienced nurse. Lye ingestion discharge, psychiatric issues, and grafts are less acute.