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The ED receives a client involved in a motor-vehicle accident. The nurse notes a large hematoma on the right flank. Which intervention should the nurse implement first?
- A. Insert an indwelling urinary catheter.
- B. Take the vital signs every 15 minutes.
- C. Monitor the skin turgor every hour.
- D. Mark the edges of the bruised area.
Correct Answer: B
Rationale: Frequent vital signs assess for hypovolemia from potential internal bleeding (flank hematoma suggests renal or retroperitoneal injury). Catheter, skin turgor, and marking are secondary.
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The ED nurse is caring for a client who had a severe allergic reaction to a bee sting. Which discharge instructions should the nurse discuss with the client?
- A. Instruct the client to wear a medical identification bracelet.
- B. Apply corticosteroid cream to the site to prevent anaphylaxis.
- C. Administer epinephrine 1:10,000 intravenously every three (3) minutes.
- D. Teach the client to avoid attracting insects by wearing bright colors.
Correct Answer: A
Rationale: A medical ID bracelet alerts others to the allergy, critical for future emergencies. Topical steroids don’t prevent anaphylaxis, IV epinephrine is hospital-based, and bright colors attract insects.
The parents bring their toddler to the ED in a panic. The parents state the child had been playing in the kitchen and got into some cleaning agents and swallowed an unknown quantity of the agents. Which health-care agency should the nurse contact at this time?
- A. Child Protective Services (CPS).
- B. The local police department.
- C. The Department of Health.
- D. The Poison Control Center.
Correct Answer: D
Rationale: The Poison Control Center provides immediate guidance on ingested toxins, critical for treatment. CPS, police, and health departments are secondary.
The ED nurse is caring for a female client with a greenstick fracture of the left forearm and multiple contusions on the face, arms, trunk, and legs. The significant other is in the treatment area with the client. Which nursing interventions should the nurse implement? List in order of priority.
- A. Determine if the client has a plan for safety.
- B. Assess the pulse, temperature, and capillary refill of the left wrist and hand.
- C. Ask the client if she feels safe in her own home.
- D. Request the significant other wait in the waiting room during the examination.
- E. Notify the social worker to consult on the case.
Correct Answer: D,C,A,B,E
Rationale: 1) Request significant other to wait (ensures private assessment); 2) Ask about safety (screens for abuse); 3) Plan for safety (addresses immediate risk); 4) Assess limb (ensures circulation); 5) Notify social worker (coordinates support).
The nurse is caring for a client diagnosed with septic shock who has hypotension, decreased urine output, and cool, pale skin. Which phase of septic shock is the client experiencing?
- A. The hypodynamic phase.
- B. The compensatory phase.
- C. The hyperdynamic phase.
- D. The progressive phase.
Correct Answer: A
Rationale: The hypodynamic (cold) phase of septic shock involves hypotension, low urine output, and cool, pale skin due to vasoconstriction. Compensatory is early, hyperdynamic is warm, and progressive involves organ failure.
The nurse is discharging a client diagnosed with accidental carbon monoxide poisoning. Which statement made by the client indicates the need for further teaching?
- A. I should install carbon monoxide detectors in my home.
- B. Having a natural bright-red color to my lips is good.
- C. You cannot smell carbon monoxide, so it can be difficult to detect.
- D. I should have my furnace checked for leaks before turning it on.
Correct Answer: B
Rationale: Bright-red lips indicate CO poisoning, not health, requiring further teaching. Detectors, odorlessness, and furnace checks are correct preventive measures.