WITH REAL EXAM QUESTIONS & GUARANTEED PASS
SUPPORT;
The nurse comes upon an automobile accident involving many cars. Which victim should the nurse
see first?
A.
The victim who is not breathing and does not have a pulse
B.
The victim who is bleeding out of both the ears, and the nose and mouth, with a blank stare
C.
The victim who is heavily bleeding bright red blood from a thigh wound
D.
The victim who is crying, complaining of arm pain, and no other apparent injuries - ANSWER--C
Rationale: The client hemorrhaging from the leg wound is the priority as of the severely injured
clients; the nurse can help the client by tying off the leg above the injury and/or applying pressure to
the wound site. When there is only one health care provider on the scene, the nurse must provide
care to those who are most likely to survive. The client without a pulse and respirations is dead. The
client with bleeding from the ears, nose, and mouth, with a blank stare, likely has severe head
trauma. The victim with arm pain and crying is the lowest priority.
The nurse is evaluating the chart of a client scheduled for surgery in 1 hour. When viewing the
consent form, the nurse notes the surgeon's signature, but not the client's signature. What steps
must the nurse take? (Select all that apply.)
A.
Call the surgeon.
B.
Ask the client, "Did your surgeon explain the procedure to you?"
C.
Have the client's spouse sign the form.
D.
Ask the client, "Do you have any questions?"
E.
Witness the signature.
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,F.
Obtain the consent. - ANSWER--B, D, E
Rationale:It is the surgeon's responsibility to review the procedure with the client until the client has
no further questions. The nurse can verify the review by the surgeon and ask if the client has any
further questions. If the client has questions, the nurse must call in the surgeon. When the nurse
signs the consent form, the nurse is witnessing the signature only.
In assisting an older adult client prepare to take a tub bath, which nursing action is most important?
A.
Check the bath water temperature.
B.
Shut the bathroom door.
C.
Ensure that the client has voided.
D.
Provide extra towels. - ANSWER--A
Rationale: To prevent burns or excessive chilling, the nurse must check the bath water temperature.
Options B, C, and D promote comfort and privacy and are important interventions but are of less
priority than promoting safety
The nurse is preparing an IV solution containing 10 mEq of potassium in 100 mL of normal saline.
Which findings would concern the nurse? (Select all that apply.)
A.
A red and swollen peripheral IV site
B.
An order to infuse the solution at 50 mL/hr
C.
Starting the infusion without an infusion devise
D.
Inverting the potassium solution every 30 minutes while infusing
E.
The solution is a lemon-yellow color - ANSWER--A, C, E
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,Rationale: Potassium can cause phlebitis. The red swollen IV site is showing signs infection. The IV
site would need to be changed before starting the solution. Potassium solutions must infuse with an
infusion devise to avoid an accidental bolus infusion. Potassium solution should be clear, and not
lemon yellow. The remaining selections are not concerning to the nurse.
The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many
milliliters should the nurse administer? _____ mL (Round to the nearest tenth.)
** 10mg/2mL - ANSWER--0.8
Rationale: (1 mL × 4 mg)/5 mg = 0.8 mL
In taking a client's history, the nurse asks about the stool characteristics. Which description should
the nurse report to the health care provider as soon as possible?
A.
Daily black, sticky stool
B.
Daily dark brown stool
C.
Firm brown stool every other day
D.
Soft light brown stool twice a day - ANSWER--A
Rationale: Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to
the health care provider promptly. Option C indicates constipation, which is a lesser priority. Options
B and D are variations of normal.
The nurse is preparing to administer a new medication through an existing IV line containing a
vasopressor. What action must the nurse take first?
A.
Flush the line with normal saline at the same rate as the vasopressor.
B.
Administer the medication at the prescribed IV rate.
C.
Start a second IV line to administer the new medication.
D.
Call the health care provider to change the order for the new medication to po. - ANSWER--A
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, Rationale: The medication in the IV line between the post and the patient contains the vasopressor
medication. The nurse must continue to administer the vasopressor medication at the prescribed
rate by injecting normal saline at that rate. Once the line is clear of the vasopressor medication, then
the nurse can inject the new medication at the prescribed rate. There is no need to start a second IV
or change the route of administration.
The nurse is working at a community-based clinic. Which client's spiritual well-being concerns the
nurse the most?
A.
Roman Catholic woman considering an abortion
B.
Jewish man considering hospice care for his wife
C.
Seventh-Day Adventist who needs a blood transfusion
D.
Muslim man who needs a total knee replacement - ANSWER--A
Rationale: In the Roman Catholic religion, any type of abortion is prohibited, so facing this decision
may place the client at risk for spiritual distress. There is no prohibition of hospice care for members
of the Jewish faith. Jehovah's Witnesses, not Seventh-Day Adventists, prohibit blood transfusions.
There is no conflict in the Muslim faith with regard to joint replacement.
The mental health nurse plans to discuss a client's depression with the health care provider in the
emergency department. There are two clients sitting across from the emergency department desk.
Which nursing action is best?
A.
Only refer to the client by gender.
B.
Identify the client only by age.
C.
Avoid using the client's name.
D.
Discuss the client another time. - ANSWER--D
Rationale: The best nursing action is to discuss the client another time. Confidentiality must be
observed at all times, so the nurse should not discuss the client when the conversation can be
overheard by others. Details of the client can be identified when referring to the client by gender or
age, even when not using the client's name.
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