A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is admitted to the hospital ED. His wife tells you that he fell down the stairs about a month ago, but “he didn’t have a scratch afterward.” She feels that he has become gradually less active and sleepier over the last 10 days or so.… Read More »
Which task should be assigned to the nursing assistant? A. Placing the client in seclusion B. Emptying the Foley catheter of the preeclamptic client C. Feeding the client with dementia D. Ambulating the client with a fractured hip Correct Answer: C. Feeding the client with dementia Of… Read More »
Which of these patients in the neurologic ICU will be best to assign to an RN who has floated from the medical unit? A. A 26-year-old patient with a basilar skull structure who has clear drainage coming out of the nose. B. A 42-year-old patient admitted several hours ago with a headache and… Read More »
A registered nurse who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? A. A middle-aged client who says “I took too many diet pills” and “my heart feels like it is racing out of my chest.” … Read More »
You are supervising a senior nursing student who is caring for a patient with a right hemisphere stroke. Which action by the student nurse requires that you intervene? A. The student instructs the patient to sit up straight, resulting in the patient’s puzzled expression. B. The student moves the patient’s tray to the… Read More »
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 »