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A gang war has resulted in 12 young males being brought to the emergency department. Which action by the nurse is priority when a gang member points a gun at a rival gang member in the trauma room?
- A. Attempt to talk to the person who has the gun.
- B. Explain to the person the police are coming.
- C. Stand between the client and the man with the gun.
- D. Get out of the line of fire and protect self.
Correct Answer: D
Rationale: Self-protection by exiting the line of fire prioritizes nurse safety, allowing for security intervention. Talking, explaining police arrival, or standing between risks harm.
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The triage nurse in a large trauma center has been notified of an explosion in a major chemical manufacturing plant. Which action should the nurse implement first when the clients arrive at the emergency department?
- A. Triage the clients and send them to the appropriate areas.
- B. Thoroughly wash the clients with soap and water and then rinse.
- C. Remove the clients’ clothing and have them shower.
- D. Assume the clients have been decontaminated at the plant.
Correct Answer: C
Rationale: Removing contaminated clothing and showering prevents ongoing chemical exposure, the first priority. Triage follows, washing is part of decontamination, and assuming decontamination is unsafe.
The charge nurse has been notified that a disaster has occurred and that all possible clients should be discharged so the floor can receive the casualties. Which client should not be discharged?
- A. The 13-year-old client who is scheduled for a tonsillectomy.
- B. The 42-year-old client scheduled for an abdominal aorta aneurysm dissection.
- C. The 76-year-old client diagnosed with a pulmonary embolus whose INR is 2.9.
- D. The 80-year-old client who is refusing to assist in activities of daily living.
Correct Answer: C
Rationale: A pulmonary embolus with INR 2.9 (therapeutic) requires ongoing anticoagulation and monitoring, precluding discharge. Tonsillectomy, aneurysm surgery, and ADL refusal are less acute.
The client with a temperature of 94°F is being treated in the ED. Which intervention should the nurse implement to directly elevate the client’s temperature?
- A. Remove the client’s clothing.
- B. Place a warm air blanket over the client.
- C. Have the client change into a hospital gown.
- D. Raise the temperature in the room.
Correct Answer: B
Rationale: A warm air blanket (e.g., Bair Hugger) directly raises core temperature in hypothermia. Removing clothing, changing gowns, or room temperature are less effective.
The nurse is providing first aid to a victim of a poisonous snake bite. Which intervention should be the nurse’s first action?
- A. Apply a tourniquet to the affected limb.
- B. Cut an 'X' across the bite and suck out the venom.
- C. Administer a corticosteroid medication.
- D. Have the client lie still and remove constrictive items.
Correct Answer: D
Rationale: Immobilizing the limb and removing constrictive items (e.g., jewelry) prevents venom spread and swelling, the first action. Tourniquets, cutting, and steroids are outdated or secondary.
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants intervention by the nurse?
- A. The UAP places a urine specimen in a biohazard bag in the hallway.
- B. The UAP uses the alcohol foam hand cleanser after removing gloves.
- C. The UAP puts soiled linen in a plastic bag in the client’s room.
- D. The UAP obtains a disposable stethoscope for a client in an isolation room.
Correct Answer: A
Rationale: Urine specimens are not biohazardous unless visibly bloody; placing in a biohazard bag is incorrect and requires intervention. Hand cleansing, linen handling, and stethoscope use are appropriate.