The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care?
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Solution
Answer B is correct. The teenager with sternal bruising might be experiencing airway and oxygenation problems and, thus, should be seen first. In answer A, the 10-yearold with lacerations might look bad but is not in distress. The client in answer C with a fractured femur should be immobilized but can be seen after the client with sternal bruising. The client in answer D with the dislocated elbow can be seen later as well.
Which of the following roommates would be most suitable for the client with myasthenia gravis?
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Solution
Answer A is correct. The most suitable roommate for the client with myasthenia gravis is the client with hypothyroidism because he is quiet. The client with Crohn’s disease in answer B will be up to the bathroom frequently; the client with pylonephritis in answer C has a kidney infection and will be up to urinate frequently. The client in answer D with bronchitis will be coughing and will disturb any roommate.
The licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching?
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Solution
Answer C is correct. The client should breathe normally during a central venous pressure monitor reading. Answer A indicates understanding because the client should be placed supine if he can tolerate being in that position. Answers B and D indicate understanding because the stop-cock should be turned off to the IV fluid, and the reading should be done at the top of the meniscus.
The licensed practical nurse is working with a registered nurse and a patient care assistant. Which of the following clients should be cared for by the registered nurse?
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Solution
Answer D is correct. The most critical client should be assigned to the registered nurse; in this case, that is the client 2 days post-thoracotomy. The clients in answers A and B are ready for discharge, and the client in answer C who had a splenectomy 3 days ago is stable enough to be assigned to an LPN.
Which of the following roommates would be best for the client newly admitted with gastric resection?
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Solution
Answer D is correct. The most suitable roommate for the client with gastric resection is the client with phlebitis because phlebitis is an inflammation of the blood vessel and is not infectious. Crohn’s disease clients, in answer A, have frequent stools that might spread infections to the surgical client. The client in answer B with pneumonia is coughing and will disturb the gastric client. The client with gastritis, in answer C, is vomiting and has diarrhea, which also will disturb the gastric client.
The nurse is preparing a client for mammography. To prepare the client for a mammogram, the nurse should tell the client:
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Solution
Answer B is correct. The client having a mammogram should be instructed to omit deodorants or powders beforehand because powders and deodorants can be interpreted as abnormal. Answer A is incorrect because there is no need for dietary restrictions before a mammogram. Answer C is incorrect because the mammogram does not replace the need for self-breast exams. Answer D is incorrect because a mammogram does not require higher doses of radiation than an x-ray.
Which action by the novice nurse indicates a need for further teaching?
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Solution
Answer A is correct. The nurse who fails to wear gloves to remove a contaminated dressing needs further instruction. Answers B, C, and D are incorrect because they indicate an understanding of the correct method of completing these tasks.
The graduate licensed practical nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority?
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Solution
Answer A is correct. When the cadaver client is being prepared to donate an organ, the systolic blood pressure should be maintained at 70mmHg or greater to ensure a blood supply to the donor organ. Answers B, C, and D are incorrect because they are unnecssary actions for organ donation.
The nurse is assigned to care for an infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin?
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Solution
Answer A is correct. Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temperature is important but will not assist in eliminating bilirubin; therefore, answer B is incorrect. Answers C and D are incorrect because they do not relate to the question.
A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?
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Solution
Answer C is correct. The client with laryngeal cancer has a potential airway alteration and should be seen first. The clients in answers A, B, and D are not in immediate danger and can be seen later in the day.