Question

A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?

Answer 1

Correct Answers:

Obtain an ECG.

Rationale :

✍️ Electrical injuries can disrupt the heart’s electrical conduction, causing life-threatening arrhythmias such as ventricular fibrillation.

✍️ The first priority is to assess the client’s cardiac rhythm with an ECG to detect dysrhythmias early.

✍️ Other interventions like wound care and pain management follow after life-threatening issues are ruled out.

✍️ Prompt cardiac evaluation is critical, especially if the shock involved the chest or heart pathway.

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Answer 2

Correct Answers:

Use 0.9% sodium chloride to perform an intermittent bladder irrigation.

Rationale :

◈ Bladder spasms and minimal drainage during continuous bladder irrigation likely indicate catheter obstruction.

◈ Intermittent irrigation with normal saline helps clear clots or debris, restoring catheter patency.

◈ It also reduces pressure buildup that causes painful bladder spasms.

◈ This is a common and safe intervention after a TURP procedure.

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Answer 3

Correct Answers:

Infection

Rationale :

▪ Leaving the urinary catheter bag on the bed allows urine to flow backward, leading to reflux and increased infection risk.

▪ A kinked IV line also compromises sterility and fluid flow, compounding infection chances.

▪ Proper drainage positioning prevents stagnation of urine, which is a medium for bacterial growth.

▪ Catheter-associated UTIs are a major concern and require strict nursing vigilance.

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Answer 4

Correct Answers:

Gag reflex

Rationale :

🔷 After moderate sedation and endoscopy, assessing the gag reflex is essential before allowing oral intake.

🔷 Absence of this reflex increases the risk of aspiration, which can lead to pneumonia or airway obstruction.

🔷 Pain and temperature are secondary concerns; protecting the airway is the priority.

🔷 Sedatives can temporarily suppress protective reflexes, requiring careful recovery monitoring.

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Answer 5

Correct Answers:

"You will need three follow-up blood tests within a 24-month period."

Rationale :

👉 Clients with primary syphilis need regular follow-up testing to confirm resolution and monitor for reinfection.

👉 Follow-up serologic testing at 6, 12, and 24 months is standard to ensure the infection responds to treatment.

👉 Syphilis is a reportable, chronic infectious disease, and monitoring helps prevent transmission.

👉 Early detection of treatment failure is essential to prevent progression to secondary or tertiary stages.

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Answer 6

Correct Answers:

Place a large-face clock in the client's bedroom.

Rationale :

✳️ Clients with Alzheimer’s disease benefit from visual cues and orientation aids, like a large-face clock.

✳️ This supports daily orientation to time and reduces confusion or sundowning.

✳️ Dim or dark rooms can worsen disorientation and agitation in patients with dementia.

✳️ Environment modification is a key part of safety and cognitive support in Alzheimer’s care.

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Answer 7

Correct Answers

Encourage the client to cough. [ Contraindicated ]
Keep the client's head in a midline position. [ Anticipated ]
Elevate the head of the bed. [ Anticipated ]
Assist the client to the bathroom. [ Contraindicated ]
Initiate seizure precautions. [ Anticipated ]
Decrease oxygen to 1.5 L/min via nasal cannula. [ Contraindicated ]

Rationale :

🔹 Encourage the client to cough

🟨 Coughing increases intracranial pressure (ICP), which is dangerous in a patient showing signs of neurological deterioration.

🟨 The client is at risk for herniation, and any action that raises pressure in the brain must be avoided.

🟨 Airway protection is important, but coughing is not the safe approach here.

🔹 Keep the client’s head in a midline position

🟨 Midline head positioning promotes venous drainage from the brain and reduces ICP.

🟨 This is a standard neurological intervention to prevent further brain injury.

🟨 It also supports cerebral perfusion pressure.

🔹 Elevate the head of the bed

🟨 Elevating the HOB to 30° facilitates cerebral venous return and decreases ICP.

🟨 It also helps optimize oxygenation, which is critical in brain injury.

🟨 This is a priority positioning measure in neurologic care.

🔹 Assist the client to the bathroom

🟨 The client is restless, confused, and has a GCS of 9, which indicates impaired consciousness and mobility.

🟨 Ambulating such a client increases fall risk and should be strictly avoided.

🟨 The client likely requires bedrest and full assistance.

🔹 Initiate seizure precautions

🟨 With declining mental status and vomiting, this patient is at high risk for seizure activity.

🟨 Seizure precautions help prevent injury and ensure rapid intervention.

🟨 This is a proactive neurologic safety measure.

🔹 Decrease oxygen to 1.5 L/min via nasal cannula

🟨 The client’s O₂ saturation is 90% despite increased oxygen, showing worsening oxygenation.

🟨 Decreasing the flow would further compromise brain oxygen supply, worsening the condition.

🟨 Oxygen should be titrated upward if needed, not down.

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Answer 8

Correct Answers

Oxygen saturation 96% at 2 L/min via nasal cannula [ Indication Of Potential Improvement ]
Disoriented to person, place, and time [ Indication Of Potential Worsening Of Condition ]
Blood pressure 100/50 mm Hg [ Indication Of Potential Worsening Of Condition ]
Hct 45% [ Unrelated To Diagnosis ]
Pink-tinged urine [ Indication Of Potential Worsening Of Condition ]
Butterfly rash [ Unrelated To Diagnosis ]

Rationale :

🔹 Oxygen saturation 96% at 2 L/min

✍️ This is an improvement from the earlier need for 3 L/min at 95%, suggesting better pulmonary function and gas exchange.

✍️ The decrease in oxygen requirement shows clinical progress.

✍️ This is a positive sign in UTI recovery.

🔹 Disoriented to person, place, and time

✍️ Worsening disorientation is a sign of delirium or sepsis progression, especially in elderly clients with UTIs and dementia.

✍️ It indicates neurological decline, not typical aging or baseline dementia.

✍️ This is a serious sign requiring immediate intervention.

🔹 Blood pressure 100/50 mm Hg

✍️ This BP reading is low compared to admission, indicating potential hypovolemia or sepsis.

✍️ It may reflect deteriorating perfusion, especially when paired with other symptoms.

✍️ Early hypotension in infection is a red flag for sepsis.

🔹 Hct 45%

✍️ Hematocrit is within normal range and not directly relevant to a UTI diagnosis.

✍️ Unless linked to volume status or bleeding, it is unrelated.

✍️ This is a neutral finding.

🔹 Pink-tinged urine

✍️ Blood in urine suggests a worsening UTI or trauma from catheterization.

✍️ It could also indicate progression to pyelonephritis or bleeding.

✍️ This is a concerning development.

🔹 Butterfly rash

✍️ The malar rash is associated with lupus, part of the client’s chronic history, not the UTI.

✍️ It does not reflect acute deterioration or recovery.

✍️ Thus, it is unrelated to current illness

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Answer 9

Correct Answers

Elevated iron levels [ Unrelated To Diagnosis ]
Increased albumin level [ Indication Of Potential Improvement ]
Productive cough Ascites [ Indication Of Potential Worsening Of Condition ]
Hematemesis [ Indication Of Potential Worsening Of Condition ]
Spontaneous bruising [ Indication Of Potential Worsening Of Condition ]

Rationale :

🔹 Elevated iron levels

◈ The client has hemochromatosis, so elevated iron is a chronic finding, not a sign of change in liver function.

◈ It is unrelated to acute cirrhosis progression.

◈ No follow-up is needed specifically for this lab alone.

🔹 Increased albumin level

◈ Albumin was previously low; an increase reflects improved liver synthetic function.

◈ This is a positive indicator for cirrhosis management.

◈ Higher albumin means better oncotic pressure and healing capacity.

🔹 Productive cough and ascites

◈ A new productive cough with fluid accumulation (ascites) could signal fluid overload or infection.

◈ This may indicate hepatic decompensation or a risk of pneumonia or SBP.

◈ It requires close monitoring and likely treatment.

🔹 Hematemesis

◈ Vomiting blood is a critical finding in cirrhosis, likely due to esophageal varices rupture.

◈ This is a life-threatening complication and requires immediate intervention.

◈ It's a hallmark of end-stage liver disease complications.

🔹 Spontaneous bruising

◈ This indicates coagulopathy, common in clients with advanced cirrhosis and poor liver function.

◈ The liver cannot produce enough clotting factors, increasing the risk for bleeding disorders.

◈ It’s a key sign of worsening liver disease.

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Answer 10

Correct Answers:

Palpable thrill

Rationale :

▪ A palpable thrill is a vibration felt over the AV graft, indicating adequate blood flow through the vascular access.

▪ This is a normal and desired finding that confirms the graft is functioning.

▪ It must be assessed routinely to detect graft patency or clotting.

▪ The absence of a thrill may mean the graft is occluded and needs urgent attention.

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Options	Anticipated	Non Essential	Contraindicated
Encourage the client to cough.
Keep the client's head in a midline position.
Elevate the head of the bed.
Assist the client to the bathroom.
Initiate seizure precautions.
Decrease oxygen to 1.5 L/min via nasal cannula.

QLexNursing

1 :
A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?

3 :
A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?

4 :
A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation. Which of the following assessment findings is the nurse's priority?

5 :
A nurse is providing instructions to a client who has primary syphilis. Which of the following instructions should the nurse include in the discharge plan?

6 :
A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?

7 :
The nurse is caring for a client.

Correct Answers

8 :
The nurse is caring for an older adult client who was admitted with a urinary tract infection.

Correct Answers

9 :
The nurse is admitting a middle-aged adult client who has cirrhosis.

Correct Answers

10 :
A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?

Options	Unrelated To Diagnosis	Indication Of Potential Improvement	Indication Of Potential Worsening Of Condition
Oxygen saturation 96% at 2 L/min via nasal cannula
Disoriented to person, place, and time
Blood pressure 100/50 mm Hg
Hct 45%
Pink-tinged urine
Butterfly rash

Options	Unrelated To Diagnosis	Indication Of Potential Improvement	Indication Of Potential Worsening Of Condition
Elevated iron levels
Increased albumin level
Productive cough Ascites
Hematemesis
Spontaneous bruising

QLexNursing

1 : A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?

3 : A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?

4 : A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation. Which of the following assessment findings is the nurse's priority?

5 : A nurse is providing instructions to a client who has primary syphilis. Which of the following instructions should the nurse include in the discharge plan?

6 : A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?

7 : The nurse is caring for a client.

Correct Answers

8 : The nurse is caring for an older adult client who was admitted with a urinary tract infection.

Correct Answers

9 : The nurse is admitting a middle-aged adult client who has cirrhosis.

Correct Answers

10 : A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?

1 :
A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?

3 :
A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?

4 :
A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation. Which of the following assessment findings is the nurse's priority?

5 :
A nurse is providing instructions to a client who has primary syphilis. Which of the following instructions should the nurse include in the discharge plan?

6 :
A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?

7 :
The nurse is caring for a client.

8 :
The nurse is caring for an older adult client who was admitted with a urinary tract infection.

9 :
The nurse is admitting a middle-aged adult client who has cirrhosis.

10 :
A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?