Nokea
The occupational health nurse is called to the scene of a traumatic amputation of a finger. Which intervention should the nurse implement prior to sending the client to the ED? Select all that apply.
- A. Rinse the amputated finger with sterile normal saline.
- B. Place the amputated finger in a sealed and watertight plastic bag.
- C. Place the amputated finger into iced saline solution.
- D. Wrap the amputated finger in saline-moistened gauze dressings.
- E. Replace the amputated finger on the hand and wrap with gauze.
Correct Answer: A,B,D
Rationale: Rinsing with saline, wrapping in moist gauze, and sealing in a plastic bag preserve the amputated finger for reimplantation. Iced saline damages tissue, and replacing on the hand is incorrect.
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During a disaster, a local news reporter comes to the emergency department requesting information about the victims. Which action is most appropriate for the nurse to implement?
- A. Have security escort the reporter off the premises.
- B. Direct the reporter to the disaster command post.
- C. Tell the reporter this is a violation of HIPAA.
- D. Request the reporter to stay out of the way.
Correct Answer: B
Rationale: Directing the reporter to the command post ensures controlled information release, adhering to HIPAA. Escorting off, citing HIPAA, or requesting to stay out are less collaborative.
The nurse in a disaster is triaging the following clients. Which client should be triaged as an Expectant Category, Priority 4, and color black?
- A. The client with a sucking chest wound who is alert.
- B. The client with a head injury who is unresponsive.
- C. The client with an abdominal wound and stable vital signs.
- D. The client with a sprained ankle which may be fractured.
Correct Answer: B
Rationale: Expectant (black) category includes unresponsive clients with minimal survival chance (e.g., severe head injury). Sucking chest wounds (red), abdominal wounds (yellow), and sprains (green) are higher priority.
The client is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first?
- A. Start an IV with an 18-gauge catheter.
- B. Administer dopamine intravenous infusion.
- C. Obtain arterial blood gases (ABGs).
- D. Insert an indwelling urinary catheter.
Correct Answer: A
Rationale: Hypovolemic shock (suggested by symptoms) requires immediate IV access for fluid resuscitation. Dopamine requires IV access, ABGs are diagnostic, and urinary catheter monitors output but is secondary.
The nurse is teaching a class about rape prevention to a group of women at a community center. Which information is not a myth about rape?
- A. Women who are raped asked for it by dressing provocatively.
- B. If a woman says no, it is a come on and she really does not mean it.
- C. Rape is an attempt to exert power and control over the client.
- D. All victims of sexual assault are women; men can’t be raped.
Correct Answer: C
Rationale: Rape is about power and control, not sexual desire, a fact. Provocative dressing, misinterpreting 'no,' and excluding male victims are myths.
The ED nurse is completing the initial assessment on a client who becomes unresponsive. Which intervention should the nurse implement first?
- A. Assess the rate and site of the intravenous fluid.
- B. Administer an ampule of sodium bicarbonate.
- C. Assess the cardiac rhythm shown on the monitor.
- D. Prepare to cardiovert the client into sinus rhythm.
Correct Answer: C
Rationale: Assessing the cardiac rhythm determines the cause of unresponsiveness (e.g., arrhythmia), guiding ACLS interventions. IV checks, bicarbonate, and cardioversion follow.