Nokea
Why does the circulating nurse remove a tightly rolled blanket from under Mrs. West’s knees?
- A. Prevent damage to nerves and circulation
- B. Provide a flat surface for the sterile field
- C. Stretch lower leg muscles to prevent strain
- D. Facilitate access to the surgical site
Correct Answer: A
Rationale: Improper positioning can cause nerve compression and circulatory issues.
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The nurse has been assigned to these clients in the emergency room. Which client would the nurse go check first?
- A. Viral pneumonia with atelectasis.
- B. Spontaneous pneumothorax with a respiratory rate of 38.
- C. Tension pneumothorax with slight tracheal deviation to the right.
- D. Acute asthma with episodes of bronchospasm.
Correct Answer: C
Rationale: Tension pneumothorax is a life-threatening condition requiring immediate attention.
Liz is an elderly woman brought in by concerned family members. After physical examination, she was diagnosed with dehydration. What assessment findings would you expect to see?
- A. Bradycardia,slowed respirations low body temperature and weight gain.
- B. Rales peripheral edema palpitations and diaphoresis.
- C. Tachypnea tachycardia hypotension poor skin turgor and decreased urinary output.
- D. Malaise lymphadenopathy fever shortness of breath and nausea.
Correct Answer: C
Rationale: The correct answer is Tachypnea, tachycardia, hypotension, poor skin turgor, and decreased urinary output (C). Dehydration leads to reduced blood volume, causing compensatory mechanisms like tachycardia and tachypnea. Poor skin turgor and decreased urinary output are classic signs of fluid loss.
Which of the following actions should the nurse carry out first in a client with a chemical splash in the eye?
- A. Flush the eyes with running water
- B. Instill an antibiotic
- C. Apply an eye pad
- D. Rub the eyes vigorously
Correct Answer: A
Rationale: Immediate flushing with water is essential to dilute and remove the chemical, preventing further damage.
Jill Means, 36, has had a vaginal radium implant placed as one of the treatments for her cervical cancer. She calls to tell you that during a coughing spell it has 'been pushed out'. You should:
- A. place signs on the door stating radioactivity danger.
- B. have Jill reinsert the applicator like a tampon.
- C. call the physician and apprise him of the situation.
- D. use forceps to place the applicator in the receptacle.
Correct Answer: D
Rationale: Signs should be placed on the door after the implant has been done, and not just when the implant is dislodged. By picking the applicator up, Jill would experience burns on her fingers/hands that would be avoidable, so need to teach her not to do so. The applicator has been contaminated, it would not be replaced in any case. Calling the physician and apprising him would certainly be necessary, but would be done after the applicator has been taken care of. Lead containers should be available to place the applicator in, and forceps would be used to do so to protect from radiation burns.
When transporting an inpatient to the surgical department, which area is a nurse from another area of the hospital able to access?
- A. Clean core
- B. Holding area
- C. Corridors of surgical suite
- D. Unprepared operating room
Correct Answer: B
Rationale: The holding area is accessible for nurses transporting patients, ensuring proper preparation before entering restricted zones.