Nursing Final (Multiple Choice + Rationale) (Chapter 39, 43, 70)

Sudden death or cardiopulmonary arrest can be caused by which of the following? select all that apply. a. laceration of a vein b. drug overdose c. drowning d. myocardial infarction e. trauma

B C D E Rationale: drowning, MI, drug overdose, trauma can all cause cardiopulmonary arrest. The laceration of a vein will cause some blood loss but not to the degree of an artery.

In an emergency, the acronym ABCDE can help you with your assessment sequence. Which of the following is the correct acronym? a. Ariway, burn care, ciculation, disability, and emergency\ b. airway, breathing, circulation, disability, exposure or examine c. airway, breathing, c-spine, disaster, and evaluate d. airway, breathing, c-spine, disability, and examine

B Rationale: N/A

A client is brought to the urgent care center with an injury to the left ankle while running. X-ray interpretation determined that there is no fracture present but the client does have a sprain. What education will the nurse reinforce to the client? a. PASS b. RICE c. RACE d. CPR

B Rationale: The acronym for treatment of a sprain is RICE—rest, ice, compression, and elevation. PASS is the acronym for using a fire extinguisher in a fire. RACE is the acronym for what actions are taken in a fire or when the smoke alarm rings. CPR is the acronym for cardiopulmonary resuscitation.

A nurse is assessing a female client diagnosed with gonorrhea. Which of the following are symptoms of gonorrhea? Select all that apply. a. yellow-green vaginal discharge b. purulent anal discharge c. cervical tenderness d. intense vulval itching e. multiple vulval warts

A B C Rationale: Yellow-green vaginal discharge, purulent anal discharge, and cervical tenderness are seen in gonorrhea. Intense vulval itching is seen in candidiasis. Multiple vulval warts are seen with human papillomavirus infection.

A 22-year-old female client who has had unprotected sex is apprehensive and wants to know more about emergency contraception. What instruction would the nurse give her about emergency contraception? a. it does not offer protection against sexually transmitted diseases b. it must be taken 72 hours after unprotected sex c. it must be taken in two doses, 24 hours apart d. it offers 100% protection against pregnancy

A Rationale: Emergency contraception offers no protection against sexually transmitted diseases. To be effective, it must begin within 72 hours after unprotected sex. Two doses of hormonal pills containing estrogen and progestin are taken 12 hours apart. Emergency contraception offers only 75% to 89% protection against pregnancy, even when it is taken within 24 hours after the unprotected sex.

a member of the safety committee is training the nurse on PASS. If a nurse must put out a fire, what would the nurse do first with the fire extinguisher? a. pull the pin b. aim at the base of the fire, near the edge c. squeeze the handles together d. sweep across the base of the fire, with a back and forth motion

A Rationale: If a nurse must put out a fire, the nurse should remember the letters PASS. P—pull the pin; A—aim at the base of the fire, near the edge; S—squeeze the handles together; S—sweep across the base of the fire, with a back and forth motion.

A client who is a victim of intimate partner violence (IPV) comes to the clinic for treatment of various bruises and lacerations. What is the priority nursing action in the care of the client? a. Document observable physical injuries with photographs. b. Inform the client that she will have to be tested for a sexually transmitted disease. c. Ask the client if this partner has had similar behaviors with other women. d. Inquire as to why the client continues to remain in an abuse situation.

A Rationale: Observable physical injuries are documented and often photographed. The primary healthcare provider will inform the client about the various testing that will be performed. There is no relevance in inquiring as to whether the partner has experienced this type of violent behavior with previous relationships. Asking the client why they remain in this abusive situation places the blame on the client, which is nontherapeutic.

The smoke alarm sounds on the unit at the long-term care facility. What acronym will guide the nurse's actions in the situation? a. RACE b. PASS c. CARE d. ACRE

A Rationale: RACE is an acronym that may help you to remember the general order of procedures for a fire:R = Rescue: Remove clients from the general area.A = Alarm/Alert: Sound alarm.C = Confine: Contain fire (close doors and windows, make sure fire doors close).E = Extinguish fire (if possible).

A 40-year-old client is planning to undergo a vasectomy. What is the information that the nurse should impart to the client? a. the procedure is relatively easy and has few complications b. the client need not use any birth control measures after vasectomy c. the client may lose his sexual potency or drive d. the client should get a sperm count again after 1 year

A Rationale: The nurse should inform the client that the procedure of vasectomy is relatively easy and has few complications. Client teaching also includes reminding the client to use birth control measures until his sperm count has remained at zero for 6 weeks, reassuring him that he will not lose his sexual potency or drive, and explaining that his sperm count should be taken again after 6 months and then yearly to assess the continuing effectiveness of the surgery.

What is the purpose of a material safety data sheet (MSDS) in a healthcare facility? a. it provides information about the physical properties of products b. it maintains a list of the chemical properties of products c. it provides a list of medications and manufacturers d. it describes the method of disposing of hazardous substances

A Rationale: The purpose of the MSDS is to provide information about the physical properties of product, its potential dangers, ingredients, and reactivity. The MSDS does not provide information about the chemical properties of products, medica-tions and their manufacturers, or the methods of disposing of hazardous substances.

A young adult female client asks about forms of chemical barrier contraception. Which is a form of a chemical barrier contraceptive? a. vaginal foam b. cervical cap c. diaphragm d. female condom

A Rationale: Vaginal foam is a chemical barrier contraceptive. It offers added contraceptive protection when used with mechanical barriers. Cervical caps, diaphragms, and female condoms are physical, not chemical barriers.

The nurse is caring for a group of clients in the women's health clinic. Which client requesting birth control pills (BCP) is at greatest risk for complications? a. A 38-year-old female who smokes cigarettes b. A 22-year-old female with a bladder infection c. A 30-year-old female that has had an IUD removed 2 months previously d. A 27-year-old female who was previously on BCP a year ago

A Rationale: Women older than 35 years who smoke are among those at the highest risk for serious conditions related to birth control pills. Complications such as pulmonary emboli are among the most dangerous. A bladder infection, having an IUD removed and previously taking birth control pills does not place a client at greater risk for complications.

Which of the following gifts for a client is most likely to be allowed in a burn unit? a. mylar balloon b. live plants c. latex balloon d. cut flowers

A Rationale: a mylar balloon is usually allowed, as it does not contain latex and this is not likely to cause an allergic reaction. Because of latex allergies, latex balloons are usually not allowed. Cut flowers and live plants are also not usually allowed in burn units due to the danger of infection.

A nurse in the pediatric ward notices a baby is missing. Which code should the nurse call? a. code pink b. code blue c. code green d. code red

A Rationale: as soon as the nurse notices that one of the babies in the pediatric ward is missing, he/she should call a Code pink. Code pink in healthcare facility is associated with missing infants. Code red is an alert in case of fire. Code blue indicates cardiopulmonary arrest. There is no code green.

A nurse is providing first aid to a client with shock signs and symptoms by doing what action first? a. elevate the person's feet on pillows and encourage the client to lie flat b. encourage the client to drink caffeinated beverages c. give a unit of packed red blood cells if ordered by the provider d. give a baby aspirin, just in case the person is having a heart attack.

A Rationale: elevating the feet can increase the blood supply to the brain. This is easy to do in the nonmedical setting and can be done by anyone. Replacing fluids, and blood products may be necessary after evaluation by a healthcare provider. Giving aspirin is not indicated in shock.

a young adult client presents to the clinic with sunburn and low-grade fever. The client reports blisters on the upper chest and shoulders following a day of water skiing. The client states the pain from the burn is "7 on a scale of 0 to 10." The nurse would document this burn as what type? a. partial thickness b. first degree c. third degree d. superficial

A Rationale: partial thickness or second-degree burns present with redness and blisters with some tissue and nerve damage

A teenaged male client asks the nurse if there is any 100% effective method of birth control and protection against sexually transmitted infections. Which should the nurse mention to him? a. continual abstinence b. birth control pills c. intrauterine device d. condoms

A Rationale: the nurse should explain to him that the only 100% effective method of birth control and protection against sexually transmitted infections is continual abstinence. Condom effectiveness ranges from about 85% to 98% and protects against HIV and other STIs. Birth control pills range in effectiveness between 95% and 99% for contraception, but the offer no protection against STIs. Intrauterine devices are 97% to 99% effective as contraceptives, but they offer no protection against STIs.

What nursing interventions should the nurse perform for a client who has frostbite? select all that apply. a. separate frozen fingers and toes with cotton wedges b. loosen any tight clothing worn by the client c. instruct the client to avoid walking if the foot is frostbitten d. use bandages, ointments, or salves on the frostbitten parts e. rub the frostbitten parts of the client with snow

A B C Rationale: When caring for a client with frostbite, the nurse should separate the frozen fingers and toes of the client with cotton wedges, loosen tight clothing worn by the client, and instruct the client to avoid walking if the foot is frostbitten. The nurse needs to avoid using bandages, ointments, or salves on the frostbitten parts of the client, and should not rub the frostbitten parts of the client, especially with snow.

The nurse is working in a healthcare facility during an earthquake that necessitates the evacuation of clients from the facility. Place clients in the correct order for evacuation. a. adolescent client admitted for sever nausea during her 4th month of pregnancy b. elderly client who is confused and uses a wheelchair to transport herself in the hallways c. middle-aged client who is on bedrest secondary to spine surgery 6 hours ago

A B C Rationale: those clients who can walk or use a wheelchair are evacuated first. In this case, the adolescent would be first because she is able to evacuate with verbal instructions only. The elderly confused client would be second as she is able to evacuate with verbal cueing and guidance of a staff member (who can also be carrying equipment or a pediatric client if needed). The bedrest client would be the last to be evacuated and would require evacuation via stretcher or sled carry.

The nurse is caring for an adult in the healthcare facility. What assessment questions would be appropriate for the nurse to evaluate the client's safety risk? Select all that apply. a. "are you right or left-handed?" b. "do you have allergies to latex?" c. "do you usually get up at night to urinate?" d. "do you have a family history of cancer?" e. "How well do you walk and transfer?"

A B C E Rationale: the nurse would assess the client for latex allergies and be cautious with medical supplies and balloons that have latex. The left-handed client may need adjustments made in how items are arranged in the room for safety. The client's ability to transfer will alert the nurse to the need for assistive devices, alarms and additional assistants for care. The client who gets up at night to void is at an increased risk for falls. The family history is important, but not specially related to safety.

A male client informs the nurse that he is unable to achieve or maintain an erection. What medications does the nurse anticipate teaching the client about? a. Sildenafil b. Tadalafil c. Gardasil d. Vardenafil e. Flibanserin

A B D Rationale: Several prescription medications are available to treat erectile dysfunction. These oral medications include: sildenafil, tadalafil, and vardenafil. The goal is to induce erection directly by chemically stimulating an increase in blood flow to the penis, which causes an erection. Gardasil is used in teenagers in order to prevent human papilloma virus (HPV). Flibanserin is used for female sexual dysfunction.

A nurse manager is briefing a newly appointed nurse on the guidelines followed by the healthcare facility for using hazardous substances. Which of the following safety tips should the nurse manager inform the newly appointed nurse about. Select all that apply. a. avoid using substances that are not labeled b. read labels carefully and note emergency information c. label and store hazardous substances in food containers d. use protective equipment when handling hazardous substances e. store aerosol products along with oxygen cylinders

A B D Rationale: The nurse manager should instruct the newly appointed nurse to avoid using substances that are not labeled, to read labels carefully and note emergency information, and to use protective equipment when handling hazardous substances. It is not advisable to label and store hazardous substances in food containers, because the label could easily be overlooked. It is not safe to store aerosol products along with oxygen cylinders, because such storage could cause fire.

A nurse notices a burning smell coming from a motorized piece of equipment. What should she do? Select all that apply. a. notify the unit supervisor of the equipment concern b. alert the maintenance department of the malfunction c. pull on the device's cord to unplug it form the outlet d. unplug the device by grasping the plug e. attempt to repair the device

A B D Rationale: the nurse should disconnect the equipment by grasping the plug and unplugging it. The nurse should then notify the maintenance department of the malfunction and notify the supervisor of the unit. The nurse should not unplug the device by pulling on the cord and should not attempt to repair the device.

A 34-year-old male client who has a history of hypertension is being evaluated at the fertility clinic. Which of the following are likely to reduce his fertility? Select all that apply. a. the client smokes marijuana regularly b. the client consumes alcohol daily c. the client has hypertension d. the client works as a clerk e. the client had an attack of mumps 5 years ago

A B E Rationale:The facts the client smokes marijuana regularly, consumes alcohol daily, and had an attack of mumps 5 years ago are factors that are likely to reduce his fertility. Having hypertension or working as a clerk is unlikely to affect his fertility.

Which actions should the emergency personnel perform when reporting an MVA? select all that apply. a. not the vehicle's condition b. make the area of accident c. note areas of intrusion such as the driver's side. d. inquire about the cause of the accident e. check for any gasoline spillage

A C E Rationale: When reporting an MVA, the emergency personnel should note the vehicle's condition; note areas of intrusion such as the driver's side, passen-ger's side, roof, front end, or back end; and check for gasoline spill, if any. In addition, the emergency personnel will also check whether the client was wearing seat belts, a helmet, or protective clothing. This information can help emergency personnel anticipate the type of injury. The emergency personnel need not ask about the cause of the accident or mark the area of accident, because this information does not help the personnel to anticipate the type of injury.

An elderly client is at the ball field watching a softball game. The client has symptoms of a heat stroke. What symptoms would the nurse identify as those of a heat stroke? select all that apply. a. increased core temperature of 104.5F b. cool skin c. hypotension d. slow pulse e. seizure activity

A C E Rationale: increased core temperature, hypotension, and seizure activity are all signs of a heat stroke. Cool skin is a sign of heat exhaustion. The client's pulse would increase in response to the low blood pressure.

A female client is diagnosed with a chlamydial infection. Which are signs and symptoms of this disorder? select all that apply. a. grayish-white vaginal discharge b. macular copper-colored rash c. spotting between menstrual periods d. wart-like spots around the anus e. vulvar itching and burning

A C E Rationale: the female client with a chlamydial infection may have vulvar itching and burning, grayish-white vaginal discharge, and spotting between menstrual periods. In syphilis, a macular copper-colored rash appears on the soles and palms, and wart-like spots may develop around the anus. Such symptoms and signs are not seen with chlamydial infections

One of the floors in the healthcare facility is on fire. The nurses are evacuating clients to safer areas. Which of the following interventions should the nurse take in rescuing the clients? Select all that apply. a. lead clients who can walk to safer areas b. carry clients who cannot walk. c. drag immobile clients out of the room on a sheet d. assist clients in wheelchairs into the elevator e. close all doors to confine the fire after evacuation

A C E Rationale:In case of fire, the nurse leads the clients who can walk to safer areas, drags immobile clients out of the room on sheets, and closes all doors to confine the fire after evacuation. The nurse need not try to carry clients unless they are children. The nurse should not attempt to rescue clients using elevators, because it is not advisable to use elevators in a fire.

What information is included on a Safety Data Sheet? Select all that apply. a. first-aid interventions for accidental exposure b. facility disaster plan c. client's medical history d. product ingredients e. fire or explosion hazards

A D E Rationale: each facility must have on file a safety data sheet (SDS) describing any substance considered hazardous. For commercial products, the SDS includes a description of the product, its ingredients, physical properties, fire or explosion hazards, and reactivity, along with information on protective equipment required, safe handling information (in case of a spill or leak), and first-aid interventions for accidental exposure. A client's medical history and the facility disaster plan are not included on the SDS.

a female client is interested in knowing the most efficient procedure for permanent sterilization in women. the nurse would discuss which option with the client? a. tubal ligation b. spermicidal creams c. diaphragm d. vasectomy

A Rationale: tubal ligation is the most common and effective procedure for permanent sterilization in women. It involves ligating or tying off the fallopian tubes so that ova cannot travel through them to the uterus, thus preventing conception. Vasectomy is a sterilization treatment for men, which involves ligating or tying off the vas deferens, the tube that transports sperm from the testes to outside the body, thus preventing conception. A diaphragm is a mechanical barrier contraceptive, and spermicidal creams are chemical barrier contraceptives. Neither of these is a procedure for permanent sterilization.

An 18-year-old male client is diagnosed with genital herpes. What client teaching should the nurse give the client? a. keep the areas moist to promote healing b. do not share food or engage in kissing c. wear synthetic underwear d. use a condom to prevent spread of the disease

B Rationale: An infected person should not share food or engage in kissing, to avoid spreading the disease. Cleanliness and dryness are essential to promote healing; therefore, the infected area should not be kept moist. Cotton and not synthetic underwear is useful. The virus is small enough to penetrate a condom. Therefore, a condom offers no protection against spread of the disease.

A nurse is caring for a client with nosebleed and a possible skull fracture. What basic steps should the nurse take to treat the nosebleed? a. use a clean hankerchief or cloth to wipe the bleeding b. do not attempt to stop the bleeding c. place the person on a flat surface to help blood circulation d. cleanse the nose with warm, sopy water

B Rationale: If the person with a nosebleed has a fractured skull, the nurse should not attempt to stop the bleeding, because doing so could increase intracranial pressure. If a sterile dressing is not readily available for a minor wound, the nurse should use a clean handkerchief or cloth. In any case of hemorrhage, but not nosebleed, the nurse should place the person on a flat surface and slightly elevate his or her feet. When a person is bitten, the nurse should cleanse the wound with warm, soapy water, and rinse the area thoroughly.

The nurse is working at the acute care facility and has been informed that there is a bus and multiple vehicle crash with 75 people seriously injured. What is the initial action that should be initiated? a. CPR b. Initiate the disaster plan. c. Call everyone in the hospital to help. d. Immediately have the provider discharge patients in preparation.

B Rationale: Initiating the disaster plan will allow multiple resources and personnel available for assistance. CPR is not indicated at this time and is not the initial response. Calling everyone in the hospital to help leaves the other clients in the hospital vulnerable and unmonitored. There is not enough time for the physicians to discharge clients and the physicians will need to be available for the disaster.

A client with an excessive bleeding has been brought to a healthcare facility. How should the nurse stop the client's bleeding? a. have the client sit down and lean forward b. place the client on a flat surface and slightly elevate the feet c. have the client lie on the side not affected by the wound d. use a tourniquet to stop client's bleeding

B Rationale: The nurse should place the client on a flat surface and slightly elevate the feet to stop bleeding while caring for a client with hemorrhage (unless the person has a head injury). A client with a nosebleed is made to sit down and lean forward. In case of chest injury, the nurse can have the person lie on the affected side, to apply pressure to the chest wall, and not on the side not affected. The nurse should not use a tourniquet to stop client's bleeding unless all other methods to stop bleeding have failed, because use of a tourniquet may necessitate later limb amputation.

A nurse is caring for a client who is recovering from surgery. The nurse receives a signal at the central station. Where should the nurse expect to find the client? a. client is in bed b. client is in the bathroom c. client has managed to get out of bed d. client has left the room

B Rationale: The nurse understands from the emergency signal that the client is in the bath-room. The client would have used the calling signal or intercom if he or she were in bed. The bed alarm or wander guard would alert the nurse if the client had moved out of bed or left the room.

A nurse has been asked to assist in triage in a disaster area. What should the nurse be prepared to do in this situation? a. provide mental support to family members b. assign victims to proper places for treatment c. provide first aid to the victims d. assist people with minor injuries

B Rationale: The nurse who is assisting in triage in a disaster area is expected to assign victims to proper places for treatment. Triage is the process of sorting and classifying injured persons to deter-mine priority of needs. The nurse is not expected to provide mental support to family members, provide first aid to the victims, or assist people with minor injuries. Instead, people with minor injuries could be asked to assist in triage.

Which procedure should the nurse follow to monitor the pupillary responses of a client during an emergency? a. ABCDE procedure b. PERRLA+C procedure c. APVU procedure d. BCLS procedure

B Rationale: While assessing a client's eye at an emergency site, the nurse should follow the PERRLA+C procedure (Pupils Equal, Round, Reactive to Light, Accommodation OK, Coordi-nated.) When assessing a person in an emergency, the acronym ABCDE would help the nurse to remember the order for assessment (Airway and cervical spine, Breathing, Circulation and bleed-ing, Disability, and Expose and examine.) The acronym AVPU is followed while conducting a neurologic assessment at an accident scene (Alert, responsive to Verbal stimuli only, responsive to Painful stimuli only, and Unresponsive.) BCLS (basic cardiac life support) includes rapid entry into the emergency medical system, performance of cardiopulmonary resuscitation (CPR), and use of techniques to clear an obstructed airway. These are not the procedures to examine eye signs in the client.

The nurse is triaging a young adult client who states, "I just want to die." What would be the safest environment to place the client in until the healthcare provider can evaluate the client? a. leave her in the triage room by herself b. a quiet room, with constant supervision c. a regular examination room d. place her back in the waiting room

B Rationale: a suicidal client should never be left alone. Limit stimulation because this may trigger agitation. A regular examination room is usually filled with objects the client could use to harm herself or himself. If the client is placed back in the waiting room, they may leave unseen.

The nurse assesses a client in the clinic who is restless and short of breath. The nurse notes a generalized rash and high-pitched sound when assessing the client. The nurse alerts the staff to call the emergency response system and would ask the client which assessment question? a. "do you have a family history of heat strokes or heat exhaustion?" b. "What medication or food do you think you are allergic to?" c. "Have you had your yearly influenza vaccine this year?" d. "when did you last have symptoms like these?"

B Rationale: anaphylactic shock is a medical emergency. The nurse would immediately assess for the cause of the allergy while having EMS or 911 in route. The client is not experiencing influenza symptoms so the vaccine status is not priority. The family history or previous episodes are also not priority at this time

An adolescent slid into third base while playing softball. The client reports hearing a "pop" sound and reports severe pain in the left ankle. The nurse assesses an obvious deformity of the left ankle. What would the first action of the nurse be? a. ask the client if they can bear weight b. check for pedal pulses c. place ice on affected extremity d. gently pull on the ankle (manual traction)

B Rationale: check for pedal pulses would be the first action to determine if vascular compromise is occurring. The nurse would not assess for weight bearing or pull on the injured extremity to avoid further injury. Ice is appropriate but not the first action.

The winter camp nurse is alerted to a client with frostbite after submersion in lake water. What action would the nurse take? a. walk the client to increase heart rates to improve circulation b. remove wet clothing and wrap in a warm blanket c. rub the extremities to increase blood flow d. place client in bath water of warm water

B Rationale: remove the wet clothing and wrap the client in a warm blanket. You must first remove the exposure to the wet cold clothing. The body temperature must be returned to baseline slowly. If soaking the frostbite body part, the water should be tepid, not warm. Rubbing the frostbitten areas will increase damage to the frozen tissues.

Which condition may be defined as the absolute inability to procreate? a. vaginismus b. sterility c. dyspareunia d. infertility

B Rationale: sterility is the absolute inability to procreate. Infertility is the inability to conceive and to produce live babies after adequate sexual exposure. Dyspareunia is painful intercourse, and vaginismus is involuntary contraction of vaginal outlet muscles, which prevents penile penetration.

A nurse is caring for an elderly client in a local healthcare facility. What intervention should the nurse perform to prevent the client from falling when getting out of bed? a. raise the height of the client's bed b. allow the client to reorient before standing c. keep bed in low position with the brakes off d. use two means to identify each client

B Rationale: the nurse should allow the client to reorient to the new position to prevent him/her from falling. Raising the height of the bed helps prevent back strain in the nurse when working with the client; the bed should be lowered when the client is getting up. Using two means to identify each client is done to make sure that the right procedure is performed or the right medication is given to the right client and does not help prevent falls. The bakes on the bed should be locked at all time to keep the bed from moving.

An adult male client is receiving a medication for erectile dysfunction (ED). The nurse will need to teach the client about which possible side effect of this type of drug? a. edema b. priapism c. infertility d. hypertension

B Rationale: the nurse should inform the client taking medication for ED that priapism, or continued erection accompanied by pain, is a side effect of ED drugs. Another side effect is hypotension. Hypertension, edema, and infertility are not side effects of medication for ED.

a nurse finds a client smoking a cigarette in the "no smoking" area of a healthcare facility. Which line of action should the nurse take? a. sound the fire alarm to prevent the spread of fire. b. ask the client to extinguish the cigarette c. notify the fire department immediately d. ask the client to leave the "no smoking" area.

B Rationale: the nurse should inform the client to extinguish the cigarette as it is a "no smoking" area. A lit cigarette does not call for a fire alarm or notification to the fire department. Just asking the client to leave the "no smoking" area is not enough; the client must be made to extinguish the cigarette.

The nurse receives report of a client presenting with loss of consciousness after a four-wheeler accident; the client is brought in the back of a pickup truck by friends. The client is unconscious, but breathing adequately, with a pulse of 120 bpm and a blood pressure of 90/40. The client's abdomen is distended and firm. The client has cool and clammy skin. What would the nurse expected this client to be treated for? a. increased intracranial pressure b. hypovolemic shock c. hypothermia d. collapsed lung/flail chest

B Rationale: this client is experiencing hypovolemic shock. The abdomen is a large space with vascular organs that can hold a large amount of volume. Increased pulse and decreased blood pressure are indicators of hypovolemia.

A client is being treated for frostbite of the toes of both feet after exposure to severe cold. The provider has issued orders. What are the likely actions that the nurse will take in caring for this client? Select all that apply. a. Rubbing the client's toes to rewarm b. Loosening tight clothing from the client c. Separating the toes with cotton wedges d. Rewarming the toes with tepid water e. Covering the feet with hot towels

B C D Rationale: The nurse needs to protect frozen body parts and handle them gently. Loosen tight clothing. Separate frozen fingers and toes with cotton wedges; however, do not use bandages, ointments, or salves. Slow rewarming with tepid, not hot water or towels is appropriate to avoid permanent tissue damage. Do not rub a frostbitten part to restore circulation; rubbing, particularly with snow, will only increase the damage and can contribute to gangrene.

A nurse is assigned the responsibility of caring for a client in a home-care setting who has severe anxiety. What should be the nurse's role for such a client? select all that apply. a. encourage the client to engage in voluntary activity b. avoid making any assumptions or judgments c. encourage the client to remain calm. d. encourage the client to talk about the cause of anxiety. e. ask the client questions that elicit "yes or no" answers

B C D Rationale: When caring for a client with severe anxiety, the nurse should encourage the client to remain calm, encourage the client to talk about the cause of the anxiety, and avoid making any assumptions or judgments. The nurse need not encourage the client to take any voluntary activity, because the client may not be in the condition for it. The nurse should avoid questions that elicit "yes or no" answers, because this would not encourage the client to talk further.

The nurse observes a large amount of smoke and some flames coming from an unoccupied room in the hospital. After calling in the alarm, what action does the nurse take? a. Lock all of the doors so people cannot enter rooms. b. Open windows to let the smoke out of the room. c. Close all doors to confine smoke and fire. d. Take the elevator to the lowest floor in the hospital.

C Rationale: After calling in the alarm, close all doors, including fire and room doors. Check to make sure "automatic" doors fully close. Close open windows. (These procedures help to confine fire and smoke.) Do not lock any doors. Do not use elevators.Do not use the telephone unnecessarily. Turn off or unplug unnecessary electrical appliances. Report to the charge nurse for further instructions.

The nurse splashes a chemical used for disinfecting surgical instruments on both hands. Which resource will provide information regarding the contents of the chemical? a. Disaster Plan b. Physician's Desk Reference c. Safety Data Sheet d. Poison Control

C Rationale: Any hazardous material in the facility must have a safety data sheet (SDS) on file. This will reveal the contents of all materials and liquids that are used in the facility and should be within easy access for all employees. A disaster plan would be used in the event of a disaster such as natural disasters (e.g., hurricane) and other events that cause mass destruction. A physician's desk reference has medication information but does not reveal information regarding chemicals and hazardous materials. Poison control would be an option for use if the information is not found in the SDS, but the SDS should be used first.

A client reports repeated fever blisters on her lips. The nurse knows that which virus is the most likely cause of this condition? a. gonorrhea b. HPV c. herpes simplex virus type 1 (HSV-1) d. Herpes simplex virus type 2 (HSV-2)

C Rationale: HSV-1 is mainly associated with non genital lesions, such as canker sores, "cold sores," or "fever blisters" of the mouth and lips. HSV-2 is associated more with genital lesions. HPV appears as genital warts, not as nongenital blisters. Gonorrhea is more likely to appear in the form of discharge from the genitals.

A client has been given the abortifacient drug, mifepristone. What should the nurse be sure to inform the client? a. There are no contraindications to taking the medication. b. You can only take this medication once because it will not work again. c. You may experience cramping and vaginal bleeding for 2 weeks. d. There may be severe vomiting and diarrhea.

C Rationale: Nearly all women who take mifepristone state that they experience cramping, vaginal bleeding or spotting for about 2 weeks. Contraindications for the use of mifepristone include the presence of an IUD, an ectopic pregnancy, hemorrhagic disorders, and specific adrenal disorders. The medication is not intended to be used as a form of regular birth control but may be taken at a future date. Severe vomiting and diarrhea should be immediately reported and is not a normal side effect of this medication.

Which is a symptom of chlamydial infection in the male client? a. chancre on the penis b. yellowish-white discharge from the penis c. pain and swelling in the testicles d. numerous warts in the genital area

C Rationale: Pain and swelling in the testicles and watery penile discharge is seen in chlamydial infection. Chancre may appear on the penis in syphilis, but not in chlamydial infection. Yellow-ish-white discharge from the penis is seen in gonorrhea, whereas warts in the genital area are seen with human papillomavirus infection, not chlamydial infection.

When a client has sustained a serious burn, what is the immediate action by the nurse? a. Apply burn cream to the area. b. Apply ice to the burned area. c. Stop the burning process. d. Remove burning fabric or other material from the skin.

C Rationale: The initial action for a client who has been burned is to stop the burning process because avoiding further damage is a priority. To stop the burning process, smother the flames with a blanket and apply cool, damp sheets to the burned area. Do not put anything other than water or a specifically prescribed substance on a burn. Materials such as salves, ointments, or butter occlude the burn so it becomes difficult to examine. These substances promote infection and pain on removal. Remove as much clothing in the burned area as is possible, if it is not stuck to the skin. Tight clothing can be especially dangerous later. Often, swelling occurs. Tight clothing contributes to swelling by hampering circulation. Removal of clothing also helps to cool the person. (Make sure the person does not become chilled.)

A nurse is caring for a left-handed client. What should the nurse consider when assisting the client out of bed or ambulating? a. provide the client with crutches b. provide the client with a wheelchair c. keep in mind that client is also "left-footed." d. provide the client with a walking stick

C Rationale: The nurse should keep in mind that the client who is left-handed is often "left-footed." The client would need crutches, a wheelchair, or walking sticks only if he or she needed additional support for walking after getting out of bed.

A 17-year-old female client has been admitted to the healthcare facility after a sexual assault. Which nursing interventions is involved in caring for this client? a. instruct the client to take a shower first b. instruct the client to douche before examination c. provide emotional support d. perform a pelvic examination immediately

C Rationale: The nurse should provide emotional support to the rape victim. A person who has been raped should not shower, bathe, or douche before examination. The nurse will assist the healthcare provider with the pelvic examination and not do it independently.

A nurse is assigned the responsibility of caring for a client who has been exposed to hazardous chemicals. Which additional precaution should the nurse undertake for this client? a. use soapy water on affected area b. apply salve over the affected area c. remove client's clothing and rise off chemicals d. cover the area with a dry, non-stick, sterile dressing

C Rationale: The nurse should remove the clothing of the client and rinse off the chemical from the clothes of the client. The nurse needs to use plenty of soapy water on the affected area when the client has been the victim of an animal bite. The nurse should not use salve over the affected area. Extensive burns are covered with dry, non-stick, sterile dressing.

A member of the disaster medical assistance team (DMAT) is explaining the functioning of DMAT during an emergency. What is the role of a DMAT? a. it provides financial support during disaster b. it provides safety equipment in an emergency c. it provides relief when there is a shortage of workers d. it provides amulating services during emergency

C Rationale: The role of the DMAT is to provide relief when there is a shortage of workers and to relieve workers who need rest. The DMAT does not provide financial support, safety equipment, or ambulating services during an emergency.

The nurse is assessing a client following treatment for life-threatening trauma. How often should vital signs be taken? a. every minute b. every 15 minutes c. every 5 minutes d. every 10 minutes

C Rationale: every 5 minutes is an adequate time to identify changes in vital signs. This time frame is realistic and a valuable tool in client assessment

A nurse is teaching an adolescent client about sexually transmitted infections (STIs). Which would the nurse include in the teaching plan? a. middle-aged and older adults are at the highest risk for infection b. implanted contraceptives provide some protection against STIs. c. females have the most reported cases of chlamydia and gonorrhea d. latex condoms provide no protection against STIs

C Rationale: females between the ages 15 and 29 account for one half of the cases of STDs, especially gonorrhea and chlamydia. Latex condoms provide some protection against STIs. Implanted contraceptives provide no protection against STIs.

The nurse is assessing a client with hypovolemic shock. The nurse is aware the client's skin is pale and cool because of what change in the body? a. the client is scared and has lost color in the chest, arms, and face b. the client has an elevated temperature causing the color change in the body c. the blood is being shunted toward the core of the body, away from the skin d. the client is not breathing adequately and showing signs of cyanosis

C Rationale: hypovolemic shock causes the body to shunt the blood to vital organs and away from the skin, thus the pale and cool appearance. The client may be scared, but this is not the cause of the pale, cool skin. Cyanosis will cause a blueish tinge to the skin and an elevated temperature will cause a flushing of the skin.

The primary assessment during an emergency situation can usually be done in what length of time? a. 30 seconds b. 45 seconds c. 60 seconds d. 90 seconds

C Rationale: one minute is adequate time to obtain an initial assessment. Time is critical.

A construction worker working near the clinic where a nurse is working runs in the door screaming, "it's burning, it's burning!" The nurse notices the client is covered in a white powder. What is the nurse's first action? a. tell him he is going to be OK and to calm down b. utilize water from the tap to wash him off c. identify the power and alert the hazmat team d. instruct him to wash his face off so he can see

C Rationale: the nurse should first assess the type of chemical and alert the hazmat team. Some chemicals react with water and you can cause further damage if water is applied.

A nurse is providing a client with information on hormonal contraception. Which could the nurse use as an example of hormonal contraception? a. Sildenafil b. Mifepristone c. Medroxyprogesterone injection d. Tadalafil

C Rationale: the nurse should inform the client that medroxyprogesterone injection is a hormonal contraceptive. Sildenafil and Tadalafil are medications designed to induce erection. Mifepristone causes abortion. They do not act as hormonal contraceptives.

The nurse is caring for a client involved in a house fire with burns to the chest and upper arms. What signs observed by nurse indicate the client may have also sustained inhalation injuries? Select all that apply. a. Fever b. Neck pain c. Flecks of soot in the saliva d. Hoarse voice e. Singed Nasal hairs

C D E Rationale: A person can experience a burn internally, such as from inhaling hot air or smoke or from swallowing a caustic substance. The signs that a client has smoke inhalation are burned or singed nasal hairs or burns in or around the mouth, flecks of soot in the client's saliva, smell of smoke on the client's breath, and a hoarse voice. Fever is a result of the initiation of the inflammatory process and is not indicative of smoke inhalation. Neck pain may be the result of injury but is not associated with smoke inhalation.

The nurse identifies the presence of a fire on the medical unit. Place the nurse's action in the correct order. a. provide emotional support to those affected by the fire b. use the fire extinguisher to put out the fire if possible c. remove any client/staff from immediate danger d. close windows and doors in the area of the fire e. activate the closest fire alarm/emergency response system

C E D B A Rationale: the acronym RACE is a way to remember the order of steps for a fire. R=rescue clients from the area, A=activate the alarm, C=contain the fire and E=extinguish if possible. Emotional support would be offered after the threat is over.

The nurse is conducting a teaching session about HIV infection. Which information would the nurse include in the teaching plan? a. women cannot transfer the HIV virus to their infant through breastfeeding b. men are more easily infected by HIV via unprotected sex than are women c. the symptoms of HIV infection are the same in men and women d. a person who has an STI and is exposed to HIV is much more likely to acquire HIV

D Rationale: A person who has an STI and is exposed to HIV is two to five times more likely to acquire HIV than is a person who does not have an STI. Women are more easily infected by HIV via unprotected sex than are men because the delicate tissues of the female reproductive tract can become scratched or irritated. Women can transfer the HIV virus to their unborn children during pregnancy and to their infants during birth or through breastfeeding

The client at risk for falling has been identified with a distinctive wrist band. How often does the nurse need to document a fall risk? a. 6 hours b. 12 hours c. 18 hours d. 24 hours

D Rationale: Fall risk must be documented at least every 24 hours on every client.

A 28-year-old client informs the nurse that she is unable to become pregnant and has been trying for about 3 months. What is the best response by the nurse? a. "That is a long time to try without having any results." b. "What do you think might be wrong with you?" c. "Maybe your partner should be tested because it probably isn't you." d. "You should consult a fertility specialist after 1 year of regular unprotected intercourse."

D Rationale: If desired conception does not occur after 1 year of regular, unprotected intercourse, the concerned parties should consult a healthcare provider. Women in their 30s may wish to consult a specialist earlier if they suspect a problem because conception decreases considerably after the age of 30. A healthcare provider will check the general health of both the man and the woman. The response that it is a long time to try is not a true statement because the age of the client is under 30 and it is not an excessive length of time to try. Insinuating that there is something wrong with the client or partner is nontherapeutic.

The nurse reports a small fire in a trashcan located in the break room. After obtaining a fire extinguisher, what is the nurse's initial action in using the extinguisher? a. Sweep across the base of the fire. b. Squeeze the handles together. c. Aim at the base of the fire, near the edge. d. Pull the pin of the fire extinguisher.

D Rationale: The first action by the nurse should be to pull the pin on the fire extinguisher, then aim at the base of the fire, near the edge. Squeezing the handles together should be the next action, then sweep across the base of the fire, with a back and forth motion. The acronym for these actions is PASS.

A client who delivered a baby 2 weeks ago asks the nurse about the use of the Today Sponge. What should the nurse tell the client about the Today sponge? a. its effectiveness is higher in women who have had children b. it is effective for up to 30 hours after insertion c. it protects against sexually transmitted infections d. it is kept in place for at least 6 hours

D Rationale: The nurse should inform the client that the Today Sponge must be kept in place for at least 6 hours to be an effective mode of contraception. It is more effective in women who are nulliparous than in women who have borne children. It is effective for up to 24 hours after insertion, not 30 hours. The sponge does not protect against sexually transmitted diseases.

Which compensatory action should the nurse perform for a client who has gone into shock as a result of a serious illness? a. maintain the client's airway b. stabilize the client's cervical spine c. move the client to a well-ventilated, cool room d. look for sings of change in the client's level of consciousness

D Rationale: The nurse should look for signs of a change in the client's level of consciousness while caring for a client who has gone into a shock due to serious illness. When assessing a client in an emergency, the nurse should maintain the person's airway even if breathing is present. If a possibility of spinal injury exists, the nurse needs to stabilize the person's cervical spine before attempting other activities. Moving the client to a well-ventilated, cool room is required for the treatment of heat stroke.

A nurse is caring for a client with botulism. What steps can the nurse suggest to the client's relatives to prevent further poisoning form botulism? a. do not eat leafy and green salads b. do not eat items that are canned at home c. avoid eating fruits and berries d. do not use food from cans with bulging tops

D Rationale: The nurse should warn clients to never use a home-canned or commercially canned item if the top is bulging. Only those fruits, berries, greens, or vegetables that are classified as poisonous (e.g., toadstools or poisonous mushrooms) should not be eaten.

A member of the safety committee in a healthcare facility is training the nurses on safety measures at the facility. What guidelines should the trainer provide the nurses? a. assist clients in wheelchairs into elevators to escape fire b. assist clients who can walk into elevators to escape fire c. tap the frayed ends of wires on my equipment d. never turn appliances on when in contact with water

D Rationale: The trainer should ask the staff mem-bers never to turn appliances on when in contact with water, because doing so could cause electro-cution. It is not advisable for anybody to use elevators when there is fire on the premises, because the electrical system may not function properly. It is always better to replace or repair the frayed ends of wires on any equipment rather than taping the ends and using the equipment.

What nursing intervention should the nurse perform for a client who has a fractured leg? a. raise the client's injured leg b. replace the ends of the bones in the fracture c. apply a roller bandage on the fracture d. apply ice on the injury site

D Rationale: While caring for a client with a fractured leg, the nurse needs to apply ice on the injured site. The nurse need not place the client's injured leg on a raised level. Also, the nurse should never attempt to replace the ends of bones in a fracture. The nurse needs to apply a roller bandage for sprains or strains, not for fractures.

A 24-year-old client approaches a nurse for information on the use of oral contraceptives. Which health problem can occur from the use of oral contraceptives? a. increased rate of pelvic inflammatory disease b. increased rate of cancers of the endometrium c. increased rate of recurrent ovarian cysts d. increased rate of strokes.

D Rationale: Women who use oral contraceptives are at an increased risk for strokes. Noncontraceptive health benefits from oral contraceptives include decreased rates of pelvic inflammatory disease, decreased rate of cancers of the endometrium, and decreased rate of recurrent ovarian cysts.

a young adult client has sustained multiple injuries in a MVA. The nurse performs an assessment and notes paradoxical chest wall movement. The client complains of shortness of breath and is coughing up blood. What chest injury would the nurse expect the provider to further assess the client for? a. cardiac tamponade b. foreign body impalement c. superficial chest wall laceration d. flail chest

D Rationale: a flail chest is caused by two or more rib fractures in two or more places. This is called paradoxical chest wall movement. Coughing up blood is also a sign of rib fractures. Shortness of breath form a flail chest results from failure of the chest to expand adequately.

The nurse is asked to serve on the healthcare facility's safety committee. The nurse understands the purpose of this committee is to do which action? a. make sure sterile packages are dry and unopened b. check all equipment routinely to ensure it is working properly c. keep floors dry and clean to prevent falls d. track injury and illness rates and prevention of future accidents

D Rationale: safety committee responsibilities include providing security services, establishing principles of worker safety and occupational health, analyzing job safety, investigating accidents, and tracking injury and illness rates. Keeping floors dry and clean, checking equipment, and making sure sterile packages are dry and unopened are tasks that the nursing staff is responsible for, not the safety committee.

A client presents to the emergency department with a steak knife impaled in his abdomen. He states, "my wife stabbed me." What would the nurses' next action be? a. gently pull the knife to the side to assess depth of injury b. remove the knife gently and apply pressure c. instruct the client to remove it and have a suture tray at bedside so the healthcare provider can suture it d. wrap gauze around the base and tape in place

D Rationale: the nurse should wrap the knife or impaled object and secure it to prevent movement. Removing or moving the knife may cause more tissue damage. The healthcare provider will assess and determine the best course of action for treatment.

The nurse is mentoring a recently licensed nurse as they care for a client who is at risk for increased intracranial pressure (ICP). Which action by the newly licensed nurse would alert the nurse to provide additional teaching to the newly graduated nurse? a. the newly licensed nurse assesses the client's orientation b. the newly licensed nurse maintains the clients head in neutral position c. the newly licensed nurse monitors the client for nausea and vomiting d. the newly licensed nurse elevates the client's legs on pillows

D Rationale: the nurse would provide teaching that the most appropriate position for a client at risk for ICP is Fowler's or semi-Fowler's. The other answer choices are actions the newly licensed nurse should take.

A nurse is informing a pregnant client about the contraceptives she can use in the postpartum period. What is a benefit of Depo-Provera? a. it provides protection against sexually transmitted diseases b. it ensures fewer chances of having an ectopic pregnancy c. it can be used in clients with cardiac disorders. d. It is 99% effective in preventing pregnancy

D Rationale:Depo-Provera is 99% effective in preventing pregnancy. However, if a pregnancy does occur, it is more likely to be an ectopic pregnancy. Depo-Provera does not provide protection against sexually transmitted diseases. It cannot be used in clients with cardiac disorders, because it may aggravate the condition.

A client has been camping in the woods in cold temperatures and is brought to the Emergency Department with suspected hypothermia. What ordered action is important at this time? a. Warm the client rapidly to a body temperature of 98.6°F. b. Apply hot packs to the skin. c. Give the client hot coffee or tea. d. Gradually rewarm the client.

D Rationale:Gradual rewarming is necessary becausewhenthe body is rewarmedtoo quickly, cold blood returns to the heart, causing severe dysrhythmia and sometimes cardiac arrest. The person's cardiac status is continually monitored during rewarming. Hot packs should not be applied since this can cause tissue damage and will not be effective with rewarming to the core of the body. Hot liquids should not be administered, especially if the client has an altered level of consciousness.