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The client has been brought to the ED by ambulance following a motor-vehicle accident with a flail chest, an intravenous line, and a Heimlich valve. Which intervention should the nurse implement first?
- A. Start a large-bore intravenous access.
- B. Request a portable chest x-ray.
- C. Prepare to insert chest tubes.
- D. Assess the cardiac rhythm on the monitor.
Correct Answer: C
Rationale: A flail chest with a Heimlich valve indicates a pneumothorax; preparing for chest tube insertion stabilizes breathing, the priority. Additional IVs, x-rays, and cardiac monitoring follow.
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Which signs/symptoms should the nurse assess in the client who has been exposed to the anthrax bacillus via the skin?
- A. A scabby, clear fluid-filled vesicle.
- B. Edema, pruritus, and a 2-mm ulcerated vesicle.
- C. Irregular brownish-pink spots around the hairline.
- D. Tiny purple spots flush with the surface of the skin.
Correct Answer: B
Rationale: Cutaneous anthrax presents with edema, pruritus, and a small ulcerated vesicle that becomes necrotic. Scabby vesicles, brownish-pink spots, and purple spots are not typical.
The father of a child brought to the emergency department is yelling at the staff and obviously intoxicated. Which approach should the nurse take with the father?
- A. Talk to the father in a calm and low voice.
- B. Tell the father to wait in the waiting room.
- C. Notify the child’s mother to come to the ED.
- D. Call the police department to come and arrest him.
Correct Answer: A
Rationale: A calm, low voice de-escalates the situation, promoting safety. Waiting room relocation, notifying the mother, or police involvement may escalate or delay resolution.
Which statement best describes the role of the medical-surgical nurse during a disaster?
- A. The nurse may be assigned to ride in the ambulance.
- B. The nurse may be assigned as a first assistant in the operating room.
- C. The nurse may be assigned to crowd control.
- D. The nurse may be assigned to the emergency department.
Correct Answer: D
Rationale: Medical-surgical nurses are often reassigned to the ED during disasters to manage increased patient loads. Ambulance, OR, and crowd control roles are less typical.
The 84-year-old female client is admitted with multiple burn marks on the torso and under the breasts along with contusions in various stages of healing. When questioned by the nurse, the woman denies any problems have occurred. The woman lives with her son and does the housework. Which is the most probable reason the woman denies being abused?
- A. There has not been any abuse to report.
- B. The client is ashamed to admit being abused.
- C. The client has Alzheimer’s disease and can’t remember.
- D. The client has engaged in consensual sex.
Correct Answer: B
Rationale: Shame often leads elderly abuse victims to deny abuse, especially when dependent on the abuser (e.g., son). Lack of abuse is unlikely given findings, Alzheimer’s is speculative, and sex is unrelated.
The unlicensed assistive personnel (UAP) is performing cardiac compressions on an adult client during a code. Which behavior warrants immediate intervention by the nurse?
- A. The UAP has hand placement on the lower half of the sternum.
- B. The UAP performs cardiac compressions and allows for rescue breathing.
- C. The UAP depresses the sternum 0.5 to one (1) inch during compressions.
- D. The UAP asks to be relieved from performing compressions because of exhaustion.
Correct Answer: C
Rationale: Compressions should depress the sternum 2–2.4 inches; 0.5–1 inch is inadequate, requiring intervention. Correct hand placement, rescue breathing, and relief requests are appropriate.