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A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable about biochemical agents, is giving directions to the travelers. Which direction should the nurse provide to the travelers?
- A. Hold their breath as much as possible.
- B. Stand up to avoid heavy exposure.
- C. Lie down to stay under the exposure.
- D. Attempt to breathe through their clothing.
Correct Answer: C
Rationale: Lying down minimizes exposure to chemical agents, which may settle lower. Breath-holding is temporary, standing increases exposure, and clothing is minimally protective.
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Which situation warrants the nurse obtaining information from a material safety data sheet (MSDS)?
- A. The custodian spilled a chemical solvent in the hallway.
- B. A visitor slipped and fell on the floor that had just been mopped.
- C. A bottle of antineoplastic agent broke on the client’s floor.
- D. The nurse was stuck with a contaminated needle in the client’s room.
Correct Answer: A
Rationale: MSDS provides handling and exposure information for chemical spills like solvents. Antineoplastic spills require specific protocols, and needle sticks or falls involve infection control or safety protocols, not MSDS.
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 nurse is assessing the client who suffered a near-drowning event. Which data require immediate intervention?
- A. The onset of pink, frothy sputum.
- B. An oral temperature of 97°F.
- C. An alcohol level of 100 mg/dL.
- D. A heart rate of 100 beats/min.
Correct Answer: A
Rationale: Pink, frothy sputum indicates pulmonary edema, a life-threatening complication requiring immediate intervention. Normal temperature, alcohol levels, and tachycardia are less urgent.
The female client presents to the emergency department with facial lacerations and contusions. The spouse will not leave the room during the assessment interview. Which intervention should be the nurse’s first action?
- A. Call the security guard to escort the spouse away.
- B. Discuss the injuries while the spouse is in the room.
- C. Tell the spouse the police will want to talk to him.
- D. Escort the client to the bathroom for a urine specimen.
Correct Answer: D
Rationale: Escorting the client to the bathroom provides a private opportunity to assess for abuse safely. Security, discussing injuries, or mentioning police may escalate the situation.
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.