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The nurse working in the emergency department is admitting a 34-year-old female client for one of multiple admissions for spousal abuse. The client has refused to leave her husband or to press charges against him. Which action should the nurse implement?
- A. Insist the woman press charges this time.
- B. Treat the wounds and do nothing else.
- C. Tell the woman her husband could kill her.
- D. Give the woman the number of a women’s shelter.
Correct Answer: D
Rationale: Providing a women’s shelter number empowers the client with resources without coercion. Insisting on charges, minimal treatment, or fear tactics disrespect autonomy.
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The male client was found in a parked car with the motor running. The paramedic brought the client to the ED with complaints of a headache, nausea, and dizziness and the client is unable to recall his name or address. On assessment, the nurse notes the buccal mucosa is a cherry-red color. Which intervention should the nurse implement first?
- A. Check the client’s oxygenation level with a pulse oximeter.
- B. Apply oxygen via nasal cannula at 100%.
- C. Obtain a psychiatric consult to determine if this was a suicide attempt.
- D. Prepare the client for transfer to a facility with a hyperbaric chamber.
Correct Answer: B
Rationale: Cherry-red mucosa suggests carbon monoxide (CO) poisoning; 100% oxygen via non-rebreather mask is the first intervention to displace CO. Pulse oximetry is unreliable, psychiatric consults are secondary, and hyperbaric transfer follows initial stabilization.
The nurse is caring for a client in the ED with abdominal trauma who has had peritoneal lavage. Which intervention should the nurse include in the plan of care?
- A. Assess for the presence of blood, bile, or feces.
- B. Palpate the client for bilateral femoral pulses.
- C. Perform Leopold’s maneuver every eight (8) hours.
- D. Collect information on the client’s dietary history.
Correct Answer: A
Rationale: Peritoneal lavage detects blood, bile, or feces, indicating internal injury. Femoral pulses, Leopold’s maneuver (pregnancy), and diet history are irrelevant.
The client presents to the ED with acute vomiting after eating at a fast-food restaurant. There has not been any diarrhea. The nurse suspects botulism poisoning. Which nursing problem is the highest priority for this client?
- A. Fluid volume loss.
- B. Risk for respiratory paralysis.
- C. Abdominal pain.
- D. Anxiety.
Correct Answer: B
Rationale: Botulism causes progressive paralysis, including respiratory muscles, making respiratory paralysis the highest priority. Fluid loss, pain, and anxiety are secondary.
The nurse is working at a facility where an Ebola client has been admitted. Which action should the nurse take?
- A. Consult the nurse manager regarding the infection-control standards to follow.
- B. Resign immediately and leave the facility.
- C. Watch the television news reports to identify which station has the client.
- D. Participate in a news report about the quality of care provided at the hospital.
Correct Answer: A
Rationale: Consulting the nurse manager ensures adherence to Ebola-specific infection control (e.g., PPE, isolation). Resigning, watching news, or participating in reports are inappropriate.
Which equipment must be immediately brought to the client’s bedside when a code is called for a client who has experienced a cardiac arrest?
- A. A ventilator.
- B. A crash cart.
- C. A gurney.
- D. Portable oxygen.
Correct Answer: B
Rationale: A crash cart contains defibrillator, medications, and airway equipment, essential for cardiac arrest. Ventilator, gurney, and oxygen are secondary or supportive.