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Questions 149

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Extract:


Question 1 of 5

After a train accident, the nurse is assigned to triage the injured. Based upon the triage protocol, which individual should be seen last?

Correct Answer: C

Rationale: Triage prioritizes life-threatening conditions. The 25-year-old with minor injuries (abrasion, swollen ankle) is the least urgent compared to potential cardiac, neurological, or traumatic injuries.

Question 2 of 5

The nurse is caring for a client with a history of stroke who has dysphagia. Which of the following interventions should the nurse implement to prevent aspiration?

Correct Answer: C

Rationale: thickening liquids to a nectar-like consistency reduces the risk of aspiration in clients with dysphagia

Question 3 of 5

A 15-year-old client is rushed to the ER after taking an entire bottle of acetaminophen (Tylenol) in a suicide attempt. The nurse's priority is obtaining which lab results?

Correct Answer: A

Rationale: Acetaminophen overdose causes hepatotoxicity. AST and ALT levels assess liver damage, which is the priority.

Question 4 of 5

A client hospitalized with MRSA is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact?

Correct Answer: D

Rationale: MRSA requires skin-to-skin contact for transmission, prevented by hand washing, gloves, and gowns under contact precautions.

Question 5 of 5

The nurse is preparing to discharge a 60-year-old woman on warfarin (Coumadin) after mitral valve replacement. Which dietary restriction should the nurse advise the client to make?

Correct Answer: C

Rationale: Green beans are high in vitamin K, which can counteract warfarin’s anticoagulant effect. Other foods listed have minimal vitamin K.

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