A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first?
a. Facial pain
b. Vital signs
c. Bone displacement
d. Airway patency
ANS: D
A patent airway is the priority. The nurse first should make sure that the airway is patent and then should determine whether the client is in pain and whether bone displacement or blood loss has occurred.
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A nurse teaches a client about self-catheterization in the home setting. Which statements should the nurse include in this client's teaching? (Select all that apply.)
a. "Wash your hands before and after self-catheterization." b. "Use a large-lumen catheter for each catheterization." c. "Use lubricant on the tip of the catheter before insertion." d. "Self-catheterize at least twice a day or every 12 hours." e. "Use sterile gloves and sterile technique for the procedure." f. "Maintain a specific schedule for catheterization."
The nurse is explaining to a patient that there are shock absorbers in his back to cushion the spine and to help it move. The nurse is referring to his:
a. Vertebral column. b. Nucleus pulposus. c. Vertebral foramen. d. Intervertebral disks.
While receiving a transfusion of packed red blood cells, a school-age child begins to experience itchy skin, hives, and wheezes. What should the nurse do first for this child?
A) Stop the transfusion. B) Obtain a blood culture. C) Slow the transfusion rate. D) Provide a diuretic as prescribed.
Which of the following positions is most appropriate following a feeding for an infant who has had surgery for pyloric stenosis?
A) Supine with feet elevated B) Fowler's C) Prone D) Right side