Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first?
A. Instruct a staff member to maintain a log of emergency care provided.
Instructing a staff member to maintain a log of emergency care provided is not the first action that the nurse should take. This is an important task, but it can be done later, after ensuring the safety of the staff and children and providing immediate care to those who need it.
B. Apply cervical spine collars to children who have suspected neck trauma.
Applying cervical spine collars to children who have suspected neck trauma is not the first action that the nurse should take. This is a priority intervention, but it can only be done after surveying the scene for potential hazards and making sure that it is safe to approach and touch the children.
C. Notify guardians of the emergency and injuries to their children.
Notifying guardians of the emergency and injuries to their children is not the first action that the nurse should take. This is a necessary step, but it can be delegated to another staff member or done after providing initial care to the children.
D. Survey the scene for potential hazards to staff and children.
Surveying the scene for potential hazards to staff and children is the correct answer. This is the first action that the nurse should take, according to the principles of emergency care. The nurse needs to assess the situation and ensure that there are no dangers such as fire, electricity, gas, or falling debris that could harm anyone at the scene. The nurse also needs to determine how many children are injured, how severe their injuries are, and what resources are available to help them.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
A. Instructing a staff member to maintain a log of emergency care provided is not the first action that the nurse should take. This is an important task, but it can be done later, after ensuring the safety of the staff and children and providing immediate care to those who need it.
B. Applying cervical spine collars to children who have suspected neck trauma is not the first action that the nurse should take. This is a priority intervention, but it can only be done after surveying the scene for potential hazards and making sure that it is safe to approach and touch the children.
C. Notifying guardians of the emergency and injuries to their children is not the first action that the nurse should take. This is a necessary step, but it can be delegated to another staff member or done after providing initial care to the children.
D. Surveying the scene for potential hazards to staff and children is the correct answer. This is the first action that the nurse should take, according to the principles of emergency care. The nurse needs to assess the situation and ensure that there are no dangers such as fire, electricity, gas, or falling debris that could harm anyone at the scene. The nurse also needs to determine how many children are injured, how severe their injuries are, and what resources are available to help them.
Similar Questions
A nurse is caring for a school-age child who is taking valproic acid. The nurse should expect the provider to order which of the following diagnostic tests?
A. Chest x-ray
Chest x-ray is not correct because it is not related to valproic acid therapy or its adverse effects.
B. Serum liver enzyme levels
Serum liver enzyme levels is correct because valproic acid can cause hepatotoxicity and liver function tests should be monitored regularly.
C. ABGS
ABGS is not correct because it is not indicated for valproic acid therapy or its adverse effects.
D. Urine culture and sensitivity
Urine culture and sensitivity is not correct because it is not related to valproic acid therapy or its adverse effects.
Full Explanation
- A. Chest x-ray is not correct because it is not related to valproic acid therapy or its adverse effects.
- B. Serum liver enzyme levels is correct because valproic acid can cause hepatotoxicity and liver function tests should be monitored regularly.
- C. ABGS is not correct because it is not indicated for valproic acid therapy or its adverse effects.
- D. Urine culture and sensitivity is not correct because it is not related to valproic acid therapy or its adverse effects.
A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan?
A. Encourage the client to take a cool sponge bath each morning.
Encourage the client to take a cool sponge bath each morning is not correct because it can increase joint stiffness and pain.
B. Administer opioid analgesia.
Administer opioid analgesia is not correct because it is not the first-line treatment for rheumatoid arthritis and can cause dependence and tolerance.
C. Increase the client's dietary iron intake.
Increase the client's dietary iron intake is indicate in rheumatoid arthritis due to anemia of chronic inflammation.
D. Restrict the client's intake of foods high in purines.
Restrict the client's intake of foods high in purines is incorrect in rheumatoid. It is an important measure in gouty arthritis.
Full Explanation
- A. Encourage the client to take a cool sponge bath each morning is not correct because it can increase joint stiffness and pain.
- B. Administer opioid analgesia is not correct because it is not the first-line treatment for rheumatoid arthritis and can cause dependence and tolerance.
- C. Increase the client's dietary iron intake is indicate in rheumatoid arthritis due to anemia of chronic inflammation.
- D. Restrict the client's intake of foods high in purines is incorrect in rheumatoid. It is an important measure in gouty arthritis.
A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the following interventions should the nurse plan to take?
A. Initiate continuous cardiac monitoring.
The nurse should initiate continuous cardiac monitoring because a magnesium level of 2.7 mEq/L indicates hypermagnesemia, which can cause cardiac dysrhythmias, hypotension, and bradycardia.
B. Administer 40 mEq/L potassium chloride PO with orange juice.
The nurse should not administer potassium chloride to a client who has hypermagnesemia because it can worsen the condition by increasing the intracellular magnesium level and decreasing the serum calcium level.
C. Provide a diet rich in legumes, nuts, and green vegetables.
The nurse should not provide a diet rich in legumes, nuts, and green vegetables to a client who has hypermagnesemia because these foods are high in magnesium and can increase the serum magnesium level.
D. Monitor the client for tetany.
The nurse should not monitor the client for tetany because tetany is a sign of hypomagnesemia, not hypermagnesemia. Hypomagnesemia can cause neuromuscular excitability, muscle spasms, and positive Chvostek's and Trousseau's signs
Full Explanation
- A. Correct. The nurse should initiate continuous cardiac monitoring because a magnesium level of 2.7 mEq/L indicates hypermagnesemia, which can cause cardiac dysrhythmias, hypotension, and bradycardia.
- B. Incorrect. The nurse should not administer potassium chloride to a client who has hypermagnesemia because it can worsen the condition by increasing the intracellular magnesium level and decreasing the serum calcium level.
- C. Incorrect. The nurse should not provide a diet rich in legumes, nuts, and green vegetables to a client who has hypermagnesemia because these foods are high in magnesium and can increase the serum magnesium level.
- D. Incorrect. The nurse should not monitor the client for tetany because tetany is a sign of hypomagnesemia, not hypermagnesemia. Hypomagnesemia can cause neuromuscular excitability, muscle spasms, and positive Chvostek's and Trousseau's signs