Nokea
The ED nurse is caring for a male client admitted with carbon monoxide poisoning. Which intervention requires the nurse to notify the rapid response team?
- A. The client has expectorated black sputum.
- B. The client reports trying to kill himself.
- C. The client’s pulse oximeter reading is 94%.
- D. The client has stridor and reports dizziness.
Correct Answer: D
Rationale: Stridor indicates airway obstruction, and dizziness suggests worsening CO toxicity, requiring rapid response. Black sputum, suicidal intent, and 94% SpO2 are less acute.
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Which statement explains the scientific rationale for having emergency suction equipment available during resuscitation efforts?
- A. Gastric distention can occur as a result of ventilation.
- B. It is needed to assist when intubating the client.
- C. This equipment will ensure a patent airway.
- D. It keeps the vomitus away from the healthcare provider.
Correct Answer: C
Rationale: Suction equipment clears vomit or secretions, ensuring a patent airway during resuscitation. Gastric distention, intubation, and HCP protection are secondary concerns.
The client with a temperature of 94°F is being treated in the ED. Which intervention should the nurse implement to directly elevate the client’s temperature?
- A. Remove the client’s clothing.
- B. Place a warm air blanket over the client.
- C. Have the client change into a hospital gown.
- D. Raise the temperature in the room.
Correct Answer: B
Rationale: A warm air blanket (e.g., Bair Hugger) directly raises core temperature in hypothermia. Removing clothing, changing gowns, or room temperature are less effective.
The nurse is teaching a class on disaster preparedness. Which are components of an emergency operations plan (EOP)? Select all that apply.
- A. A plan for practice drills.
- B. A deactivation response.
- C. A plan for internal communication only.
- D. A preincident response.
- E. A security plan.
Correct Answer: A,B,D,E
Rationale: An EOP includes practice drills, deactivation, preincident planning, and security. Communication plans include external stakeholders, not just internal.
The nurse is providing first aid to a victim of a poisonous snake bite. Which intervention should be the nurse’s first action?
- A. Apply a tourniquet to the affected limb.
- B. Cut an 'X' across the bite and suck out the venom.
- C. Administer a corticosteroid medication.
- D. Have the client lie still and remove constrictive items.
Correct Answer: D
Rationale: Immobilizing the limb and removing constrictive items (e.g., jewelry) prevents venom spread and swelling, the first action. Tourniquets, cutting, and steroids are outdated or secondary.
The client diagnosed with septicemia is receiving a broad-spectrum antibiotic. Which laboratory data require the nurse to notify the health-care provider?
- A. The client’s potassium level is 3.8 mEq/L.
- B. The urine culture indicates high sensitivity to the antibiotic.
- C. The client’s pulse oximeter reading is 94%.
- D. The culture and sensitivity is resistant to the client’s antibiotic.
Correct Answer: D
Rationale: Antibiotic resistance requires immediate HCP notification to adjust therapy. Normal potassium, sensitive cultures, and 94% SpO2 are not urgent.