A newly admitted client diagnosed with Hodgkin’s disease undergoes an excisional cervical lymph node biopsy under local anesthesia. What does the nurse assess first after the procedure? A. Vital signs B. Incision site C. Airway D. Level of consciousness Correct Answer: C. Airway Assessing for an open airway is… Read More »
During the administration of chemotherapy agents, Nurse Oliver observed that the IV site is red and swollen when the IV is touched Stacy shouts in pain. The first nursing action to take is: A. Notify the physician. B. Flush the IV line with saline solution. C. Immediately discontinue the infusion. D. Apply an… Read More »
The patient who had a stroke needs to be fed. What instruction should you give to the nursing assistant who will feed the patient? A. Position the patient sitting up in bed before you feed her. B. Check the patient’s gag and swallowing reflexes. C. Feed the patient quickly because there are… Read More »
After receiving a dose of penicillin, a client develops dyspnea and hypotension. Nurse Celestina suspects the client is experiencing anaphylactic shock. What should the nurse do first? A. Page an anesthesiologist immediately and prepare to intubate the client. B. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary. C. Administer… Read More »
A triage nurse has these four (4) clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first? A. A 2-month-old infant with a history of rolling off the bed and has bulging fontanelle with crying B. A teenager who got a singed beard… Read More »
Nurse John is caring for clients in the outpatient clinic. Which of the following phone calls should the nurse return first? A. A client with hepatitis A who states, “My arms and legs are itching.” B. A client with a cast on the right leg who states, “I have a funny feeling in my… Read More »
Nurse Sarah is caring for clients on the surgical floor and has just received a report from the previous shift. Which of the following clients should the nurse see first? A. A 35-year-old admitted three hours ago with a gunshot wound; 1.5 cm area of dark drainage noted on the dressing. B. A 43-year-old… Read More »
When prioritizing care, which of the following clients should the nurse Olivia assess first? A. A 17-year-old client 24-hours post appendectomy. B. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome. C. A 50-year-old client 3 days post myocardial infarction. D. A 50-year-old client with diverticulitis. Correct… Read More »
A nurse is caring for an elderly Vietnamese patient in the terminal stages of lung cancer. Many family members are in the room around the clock performing unusual rituals and bringing ethnic foods. Which of the following actions should the nurse take? A. Restrict visiting hours and ask the family to limit visitors to… Read More »
The charge nurse on the cardiac unit is planning assignments for the day. Which of the following is the most appropriate assignment for the float nurse that has been reassigned from labor and delivery? A. A one-week postoperative coronary bypass patient, who is being evaluated for placement of a pacemaker prior to discharge. B. A… Read More »