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Question 1 of 5
What is the priority intervention for a client experiencing a stroke?
Correct Answer: A
Rationale: The correct answer is A: Administer thrombolytics. Thrombolytics help dissolve blood clots causing the stroke, restoring blood flow to the brain. This intervention is time-sensitive to prevent further brain damage. Administering aspirin (B) is important but not the priority over thrombolytics. Performing an ECG (C) assesses heart function, not the immediate intervention for stroke. Administering corticosteroids (D) is not indicated in acute stroke management.
Question 2 of 5
What is the priority nursing action for a client experiencing anaphylaxis?
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for anaphylaxis as it quickly reverses severe allergic reactions. It works by constricting blood vessels, relaxing airway muscles, and increasing heart rate. These actions help to counteract the potentially life-threatening symptoms of anaphylaxis, such as difficulty breathing and a drop in blood pressure. Applying antihistamines (B) may help with mild allergic reactions but are not sufficient for anaphylaxis. Administering morphine (C) or pain relief (D) is not appropriate initially as they do not address the immediate life-threatening nature of anaphylaxis.
Question 3 of 5
A nurse is providing education to a patient with diabetes about self-management. Which of the following statements by the patient indicates the need for further education?
Correct Answer: B
Rationale: The correct answer is B because taking insulin only when blood sugar is high is incorrect and can lead to dangerous complications. Step 1: Insulin should be taken as prescribed by the healthcare provider, not based solely on blood sugar levels. Step 2: Checking blood sugar regularly (A) is essential for diabetes management. Step 3: Eating a balanced diet and exercising regularly (C) are crucial for diabetes control. Step 4: Reporting signs of infection to the healthcare provider (D) is important due to diabetes-related complications.
Question 4 of 5
Which injury is the highest priority for a client entering the Emergency Department?
Correct Answer: C
Rationale: The correct answer is C, stab wound to the chest. This injury is the highest priority because it poses the greatest risk to the client's life due to potential damage to vital organs and major blood vessels. Immediate intervention is crucial to prevent severe bleeding, pneumothorax, or cardiac tamponade. Treating this injury promptly can significantly increase the client's chances of survival. The other choices are incorrect because: A: An open leg fracture, while serious, does not typically pose an immediate life-threatening risk compared to a stab wound to the chest. B: An open head injury can be severe, but not all head injuries are immediately life-threatening. D: Traumatic amputation of a thumb, while traumatic and painful, is not a priority compared to injuries that directly threaten a client's life.
Question 5 of 5
What is the nurse's first priority when caring for a client who is in respiratory distress?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. In respiratory distress, the priority is to ensure adequate oxygenation. Oxygen therapy helps improve oxygen levels in the blood and relieve respiratory distress. Administering diuretics (B) may not address the immediate need for oxygen. Increasing respiratory rate (C) may lead to worsening distress if the underlying cause is not addressed. Administering IV fluids (D) is not the priority unless specifically indicated for the client's condition. It is crucial to prioritize oxygen delivery to support vital functions and stabilize the client's condition.
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