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Question 1 of 5

A nurse is the first on the scene of a motor vehicle accident. The victim has sucking sounds with respirations at a chest wound site and tracheal deviation toward the uninjured side. Until others arrive, the priority nursing action would be to

Correct Answer: A

Rationale: implementation, in an open pneumothorax, air enters the pleural cavity through an open wound; placing a sterile dressing loosely over the wound allows air to escape but not reenter the pleural space

Question 2 of 5

The nursing care plan for a five-year-old with a closed head injury should contain which of the following?

Correct Answer: B

Rationale: early signs of increased intracranial pressure are alterations in orientation

Question 3 of 5

The nurse is caring for a client with a nasogastric (NG) tube. Which of the following actions should the nurse take to ensure proper functioning of the NG tube?

Correct Answer: B

Rationale: checking residual volume ensures the tube is functioning and prevents overfeeding or aspiration

Question 4 of 5

A client has come to the clinic for a hepatitis B vaccine and asks if he has to be re-vaccinated after his first injection. Which of the following responses by the nurse is BEST?

Correct Answer: B

Rationale: hepatitis B vaccine is repeated at one and six months

Question 5 of 5

The nurse is caring for a 74-year-old man with type I diabetes. The client is scheduled for cataractsurgery under general anesthesia at 9 AM. The man usually receives 30 units of NPH and 10 units of regular insulin each morning at 7 AM. At 7 AM the morning of surgery, the nurse would expect to take which of the following actions?

Correct Answer: A

Rationale: usually use sliding scale with regular insulin based on blood glucose readings

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