Nokea
A nurse assesses a client admitted with a brown recluse spider bite. Which priority assessment should the nurse perform to identify complications of this bite?
- A. Ask the client about pruritus at the bite site.
- B. Inspect the bite site for a purple center.
- C. Assess the extremity for redness and swelling.
- D. Monitor the client's temperature every 4 hours.
Correct Answer: D
Rationale: Fever and chills indicate systemic toxicity from a brown recluse spider bite, which can lead to severe complications like hemolytic reactions or kidney failure. Monitoring temperature is the priority. Other assessments are relevant but not as critical for detecting systemic complications.
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A nurse is teaching a wilderness survival class. Which statements should the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.)
- A. Wear synthetic clothing instead of cotton to keep your skin dry.
- B. Drink plenty of fluids. Brandy can be used to keep your body warm.
- C. Remove your hat when exercising to prevent the loss of heat.
- D. Layer clothing to trap heat effectively.
- E. Know your physical limits. Come in out of the cold when limits are reached.
Correct Answer: A,D,E
Rationale: Synthetic clothing wicks moisture, layering traps heat, and knowing physical limits prevents overexposure. Alcohol like brandy causes heat loss, and removing a hat during exercise increases heat loss, both of which are incorrect.
An emergency department nurse assesses a client admitted after a lightning strike. Which assessment should the nurse complete first?
- A. Electrocardiogram (ECG)
- B. Electroencephalogram (EEG)
- C. Creatine kinase
- D. Computed tomography of head
Correct Answer: A
Rationale: Clients who survive a lightning strike can have serious myocardial injury. An ECG is the priority to assess for cardiac complications. Other assessments should be completed but are not the priority.
An emergency department nurse cares for a middle-aged mountain climber who is confused and exhibits bizarre behaviors. After administering oxygen, which priority intervention should the nurse implement?
- A. Administer dexamethasone (Decadron).
- B. Complete a mental status examination.
- C. Request the client for computed tomography of the brain.
- D. Request a psychiatric consult.
Correct Answer: A
Rationale: The client is exhibiting signs of mountain sickness and high altitude cerebral edema (HACE). Dexamethasone reduces cerebral edema by acting as an anti-inflammatory in the central nervous system. The other interventions will not treat mountain sickness or HACE.
A provider prescribes Crotalidae Polyvalent Immune Fab (CroFab) for a client who is admitted after being bitten by a pit viper snake. Which assessment should the nurse complete prior to administering this medication?
- A. Inspect the temperature for signs of fever.
- B. Check the client's creatine kinase level.
- C. Ask about allergies to pineapple or papaya.
- D. Inspect the skin for signs of internal hives.
Correct Answer: C
Rationale: CroFab is an antivenom for pit viper bites. Assessing for allergies to pineapple or papaya (due to bromelain and papain components) is critical to prevent hypersensitivity reactions. Other assessments are relevant but not the priority before administration.
A provider prescribes a rewarming bath for a client who presents with partial-thickness frostbite. Which action should the nurse take prior to starting this treatment?
- A. Administer intravenous morphine.
- B. Wrap the limb with a compression dressing.
- C. Massage the frostbitten areas.
- D. Assess the limb for compartment syndrome.
Correct Answer: A
Rationale: Rapid rewarming in a water bath is recommended for frostbite, but it causes severe pain. Administering IV morphine prior to treatment is essential for pain management. Wrapping with a compression dressing or massaging the area can cause further tissue damage, and assessing for compartment syndrome is not the priority before rewarming.