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Questions 149

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Question 1 of 5

The nurse in the emergency department is responsible for the triage of four recently admitted clients. Which client should the nurse send directly to the treatment room?

Correct Answer: C

Rationale: Exertional shortness of breath may indicate a cardiac or respiratory emergency, requiring immediate attention.

Question 2 of 5

A client develops anaphylaxis syndrome and loses consciousness after eating fruit salad containing kiwi fruit, to which the client is severely allergic. The nurse is aware that the initial concern is which of the following?

Correct Answer: A

Rationale: In anaphylaxis with unconsciousness, the initial priority is to establish a patent airway (
A) to ensure adequate oxygenation. Epinephrine (
D), oxygen (
C), and fluids (
B) follow but are secondary to airway management.

Question 3 of 5

The charge nurse witnesses the nursing assistant hitting the client in the long-term care facility. The nursing assistant can be charged with:

Correct Answer: C

Rationale: Hitting a client is assault, a criminal act of physical harm.

Question 4 of 5

The nurse is part of an interdisciplinary team in a rehabilitation unit. Which of the following statements by a client is most important to be communicated to the social worker on the team?

Correct Answer: A

Rationale: Inability to afford help (
A) is a social issue requiring the social worker's intervention for resources. Other concerns (B, C,
D) are addressed by therapy or nursing.

Question 5 of 5

The nurse is assessing a newborn 24 hours after birth. Which of the following findings would require further evaluation?

Correct Answer: C

Rationale: milia are normal, but persistent or widespread milia may indicate other issues; other findings are within normal limits for a newborn

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