Question

The nurse is caring for a client who states, "I took a handful of aspirin tablets about 6 hours ago, and now I am feeling dizzy and nauseated." Which of the following interventions should the nurse anticipate?

Answer 1

Correct Answers:

Administer sodium bicarbonate.

Rationale :

💊Sodium bicarbonate is indicated in salicylate (aspirin) poisoning to alkalinize the urine, which promotes the renal excretion of salicylates and helps prevent toxicity.

💉This treatment is especially important when signs such as nausea, dizziness, and metabolic disturbances occur after overdose.

🧪The therapeutic goal is to correct metabolic acidosis and support excretion since aspirin overdose often leads to acid-base imbalance.

🚨Acetylcysteine is the antidote for acetaminophen, not aspirin, and gastric lavage is not useful 6 hours post-ingestion as the drug is already absorbed.

📌Core Message

Sodium bicarbonate is used to treat aspirin overdose by alkalinizing urine to promote excretion and manage metabolic acidosis.

Answer 2

Correct Answers:

Monitor the client's calcium level.

Rationale :

🦴Following a subtotal thyroidectomy, there's a risk of parathyroid gland injury or removal, which can result in hypocalcemia.

💉The nurse must monitor serum calcium levels closely, as low calcium can lead to tetany, seizures, or laryngeal spasms, all of which are serious postoperative complications.

🔔Early signs of hypocalcemia include numbness, tingling, and muscle cramps, which must be identified and treated promptly.

📈While hoarseness may occur due to intubation or laryngeal nerve irritation, calcium imbalance is the priority due to its potential for rapid deterioration.

📌Core Message

Monitoring calcium levels is critical after thyroid surgery due to the risk of hypocalcemia from parathyroid disruption.

Answer 3

Correct Answers:

"I told my child that guns and bullets are dangerous, and I placed them in a locked box under the bed."

Rationale :

🔫Storing firearms under the bed, even in a locked box, is not safe for a child’s environment as it still provides easy access and increases risk of accidental injury.

🧰Guns should be stored unloaded, locked in a gun safe, with ammunition kept separately in another locked container.

🚨Children are naturally curious, and even if instructed, they may explore unsafe areas, especially if they know a weapon is present.

👪The other caregiver statements reflect appropriate age-specific safety and emergency planning for a 4-year-old.

📌Core Message

Firearms must be stored securely and out of a child’s reach, not under a bed—even if locked.

Answer 4

Correct Answers:

metabolic alkalosis

Rationale :

📉An elevated pH of 7.50 indicates alkalosis, and the normal PaCO2 value suggests the lungs are not the source of the imbalance.

🧪The HCO3 level of 35 mEq/L is significantly elevated, which is consistent with metabolic alkalosis, where bicarbonate levels are increased.

🩺This condition can result from excessive vomiting, diuretic use, or antacid overuse, all of which cause loss of hydrogen ions or gain of bicarbonate.

🔬Respiratory causes would show abnormal PaCO2, which is not present in this ABG report.

📌Core Message

High pH with elevated bicarbonate confirms metabolic alkalosis, not a respiratory origin.

Answer 5

Correct Answers:

Applies lotion over the feet and between toes

Rationale :

🦶Older adults are at increased risk for fungal infections like tinea pedis, particularly when moisture is trapped between the toes.

💧Applying lotion between toes promotes a damp environment, ideal for fungal growth, and should be avoided.

🛁The other behaviors—lukewarm baths, filing nails straight, and cleaning hearing aids properly—are safe and recommended.

🩺Nurses should educate older adults to keep feet dry, especially between toes, to prevent infections.

📌Core Message

Avoid applying lotion between toes in older adults to reduce risk of fungal infections.

Answer 6

Correct Answers:

Lowers the wheelchair footrests prior to client transfer

Rationale :

♿Lowering wheelchair footrests before transferring the client increases the risk of tripping or injury, as the client could stumble over them.

🔁Proper transfer technique involves first raising footrests out of the way, ensuring a clear and safe path for the client.

🦯The other actions—holding cane on the unaffected side, using lukewarm water for dentures, and turning hearing aid volume down—are all correct assistive device procedures.

✅Observation and correction of unsafe practices during transfers is essential to prevent falls.

📌Core Message

Footrests should be raised during transfers to prevent tripping hazards and injury.

Answer 7

Correct Answers:

Teaches the mother to verify the identification of all staff members

Rationale :

🆔Newborn safety protocols require that parents are educated to verify staff ID badges before releasing the infant, ensuring protection against abduction.

🚨Teaching the mother this practice supports active participation in infant security and enhances safety.

📸Photographing infants for social media may violate privacy and increases security risks.

🔒Removing ID bands and leaving the infant unattended in a bassinet both compromise hospital security procedures.

📌Core Message

Instructing parents to verify staff identification enhances newborn security and prevents unauthorized access.

Answer 8

Correct Answers:

admitted 1 day ago for a transient ischemic attack (TIA) with a normal MRI of the head

Rationale :

🧠A transient ischemic attack (TIA) is a temporary neurological event that typically resolves within 24 hours and does not result in permanent damage.

📊A normal MRI indicates no acute stroke, and if the client is stable, discharge with follow-up is often appropriate.

🏥The other clients present with active or unresolved conditions such as dyspnea post-CABG, active arrhythmia on diltiazem drip, or ECG changes from hyperkalemia, requiring continued monitoring.

🔄Selecting the most stable client for discharge is based on the least immediate risk of deterioration.

📌Core Message

A stable TIA client with a normal MRI is an appropriate discharge candidate due to resolved symptoms and low risk of complications.

Answer 9

Correct Answers:

laboring client whose newborn's head is emerging and retracting from the perineum with pushing

Rationale :

🚨This finding indicates shoulder dystocia, a serious obstetric emergency where the baby’s shoulders are stuck after the head delivers.

🧷This requires immediate intervention (e.g., McRoberts maneuver, suprapubic pressure) to avoid fetal hypoxia or trauma.

🧸Other scenarios like mild jaundice, laceration pain, or irregular preterm contractions are not urgent or immediately life-threatening.

👶The priority is always airway and circulation for both mother and baby during delivery.

📌Core Message

Shoulder dystocia is a priority emergency during labor that demands rapid response to prevent fetal compromise.

Answer 10

Correct Answers:

Administer indomethacin.

Rationale :

💊Indomethacin is a prostaglandin inhibitor used to treat patent ductus arteriosus (PDA) in preterm infants.

🔬It promotes closure of the ductus arteriosus, which is essential to reduce excessive blood flow to the lungs causing tachypnea and tachycardia.

👶Surgical repair is only considered if medication fails; knee-chest position is not effective in PDA management.

📈Blood pressure discrepancies between limbs are characteristic of coarctation of the aorta, not PDA.

📌Core Message

Indomethacin helps close a PDA, improving symptoms of circulatory overload in preterm infants.

1 :
The nurse is caring for a client who states, "I took a handful of aspirin tablets about 6 hours ago, and now I am feeling dizzy and nauseated." Which of the following interventions should the nurse anticipate?

2 :
The nurse is planning care for a client who just underwent a subtotal thyroidectomy. Which of the following interventions should the nurse include in the client's postoperative plan of care?

3 :
The pediatric nurse has taught the caregiver of a 4-year-old about age-appropriate safety precautions. Which of the following statements by the caregiver would require follow-up?

4 :
A nurse is reviewing laboratory tests for a client.

Answer Options

5 :
The community health nurse is observing an older adult client who lives alone. Which of the following actions by the client would require the nurse to intervene?

6 :
The nurse is observing a staff member caring for 4 clients who use assistive devices. Which of the following actions by the staff member would cause the nurse to intervene?

7 :
The nurse observes a coworker who is caring for a newborn client. Which of the following actions by the coworker would indicate to the nurse an understanding of proper security procedures for newborn clients?

8 :
The charge nurse must discharge a client from the telemetry unit to make a bed available for a client waiting for admission. It would be most appropriate for the charge nurse to recommend discharge for the client who was

9 :
The charge nurse has received a change-of-shift report on the following clients. It would be a priority for the nurse to follow up with the

10 :
The nurse is planning care for a premature 6-day-old infant with a patent ductus arteriosus who is tachycardic and tachypneic. Which of the following actions should the nurse anticipate?

1 : The nurse is caring for a client who states, "I took a handful of aspirin tablets about 6 hours ago, and now I am feeling dizzy and nauseated." Which of the following interventions should the nurse anticipate?

2 : The nurse is planning care for a client who just underwent a subtotal thyroidectomy. Which of the following interventions should the nurse include in the client's postoperative plan of care?

3 : The pediatric nurse has taught the caregiver of a 4-year-old about age-appropriate safety precautions. Which of the following statements by the caregiver would require follow-up?

4 : A nurse is reviewing laboratory tests for a client.

Answer Options

5 : The community health nurse is observing an older adult client who lives alone. Which of the following actions by the client would require the nurse to intervene?

6 : The nurse is observing a staff member caring for 4 clients who use assistive devices. Which of the following actions by the staff member would cause the nurse to intervene?

7 : The nurse observes a coworker who is caring for a newborn client. Which of the following actions by the coworker would indicate to the nurse an understanding of proper security procedures for newborn clients?

8 : The charge nurse must discharge a client from the telemetry unit to make a bed available for a client waiting for admission. It would be most appropriate for the charge nurse to recommend discharge for the client who was

9 : The charge nurse has received a change-of-shift report on the following clients. It would be a priority for the nurse to follow up with the

10 : The nurse is planning care for a premature 6-day-old infant with a patent ductus arteriosus who is tachycardic and tachypneic. Which of the following actions should the nurse anticipate?

1 :
The nurse is caring for a client who states, "I took a handful of aspirin tablets about 6 hours ago, and now I am feeling dizzy and nauseated." Which of the following interventions should the nurse anticipate?

2 :
The nurse is planning care for a client who just underwent a subtotal thyroidectomy. Which of the following interventions should the nurse include in the client's postoperative plan of care?

3 :
The pediatric nurse has taught the caregiver of a 4-year-old about age-appropriate safety precautions. Which of the following statements by the caregiver would require follow-up?

4 :
A nurse is reviewing laboratory tests for a client.

5 :
The community health nurse is observing an older adult client who lives alone. Which of the following actions by the client would require the nurse to intervene?

6 :
The nurse is observing a staff member caring for 4 clients who use assistive devices. Which of the following actions by the staff member would cause the nurse to intervene?

7 :
The nurse observes a coworker who is caring for a newborn client. Which of the following actions by the coworker would indicate to the nurse an understanding of proper security procedures for newborn clients?

8 :
The charge nurse must discharge a client from the telemetry unit to make a bed available for a client waiting for admission. It would be most appropriate for the charge nurse to recommend discharge for the client who was

9 :
The charge nurse has received a change-of-shift report on the following clients. It would be a priority for the nurse to follow up with the

10 :
The nurse is planning care for a premature 6-day-old infant with a patent ductus arteriosus who is tachycardic and tachypneic. Which of the following actions should the nurse anticipate?