Nokea
A client is rushed to the emergency department after exposure to radioactive materials in a workplace accident. The client's supervisor phoned ahead and informed the charge nurse of the chemical with which the client came in contact. What should be the initial action of the nurse?
- A. Remove all the client's clothing and decontaminate the client.
- B. Ask the client what happened during the accident.
- C. Decontaminate the room where the client was staying.
- D. Save the clothing for analysis.
Correct Answer: A
Rationale: Removing clothing and decontaminating the client is the initial action to minimize radiation exposure.
You may also like to solve these questions
The nurse is caring for a client who has been physically violent towards staff. The nurse prepares to restrain the client using
- A. soft wrist restraints.
- B. mitten restraints.
- C. elbow restraints.
- D. waist belt restraint.
Correct Answer: A
Rationale: Soft wrist restraints are appropriate for preventing harm in violent clients while allowing some movement. Other options are less suitable.
The nurse recognizes which of the following would contraindicate the use of electronic blood pressure monitoring?
- A. Coarse tremors
- B. Intrajugular central vascular access device
- C. Wearing a wrist watch
- D. Cardiac pacemaker
Correct Answer: A
Rationale: Coarse tremors can interfere with accurate electronic blood pressure readings. Intrajugular devices, wrist watches, and pacemakers do not typically contraindicate use.
The nurse is preparing to administer a low-cleansing enema to a client. Which action by the nurse is appropriate during the administration of the enema?
- A. Administer the enema with the client in a supine position.
- B. Insert the enema tube 2 inches into the rectum.
- C. Use cold tap water for the enema solution.
- D. Hang the enema bag approximately 12 inches above the client's rectum.
Correct Answer: D
Rationale: Hanging the bag 12 inches above the rectum ensures proper flow. Supine position is incorrect, insertion is 3-4 inches, and cold water causes cramping.
The nurse is performing perineal care for a female client. It would be appropriate for the nurse to
- A. Clean the client from the anal area to the urethral area.
- B. Vigorously dry the area with a clean towel.
- C. Ensure that the client's door is kept closed during the procedure.
- D. Use warm water and a soap containing alcohol.
Correct Answer: C
Rationale: Closing the door ensures privacy during perineal care. Cleaning backward risks infection, vigorous drying irritates, and alcohol-soap is harsh.
The nurse is preparing to insert a nasogastric tube (NGT). Which action should the nurse take?
- A. Rinse the tube with warm, soapy water
- B. Perform hand hygiene
- C. Don sterile gloves
- D. Obtain a computed tomography (CT) scan to verify placement
Correct Answer: B
Rationale: Hand hygiene is essential before NGT insertion to prevent infection. Rinsing with soapy water is incorrect, clean gloves suffice, and CT is not used for verification.