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A nurse assesses a client recently bitten by a coral snake. Which assessment should the nurse complete first?
- A. Unilateral peripheral swelling
- B. Clotting times
- C. Cardiac rhythm
- D. Electrocardiogram rhythm
Correct Answer: C
Rationale: Coral snake venom is neurotoxic, causing ascending paralysis and respiratory compromise. Assessing cardiac rhythm is critical to detect early signs of systemic effects. Swelling and clotting issues are more associated with pit viper bites, and ECG rhythm is redundant with cardiac rhythm.
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On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 100.1°F, pulse 120 beats/min, respirations 20 breaths/min, blood pressure 100/66 mm Hg. Which action should the nurse take?
- A. Encourage the client to drink cool water or sports drinks.
- B. Start an intravenous line and infuse normal saline.
- C. Apply cooling blankets.
- D. Administer acetaminophen.
Correct Answer: B
Rationale: The client is showing signs of heat exhaustion, characterized by confusion, elevated temperature, and low blood pressure. Starting an IV and infusing normal saline is critical to restore hydration and stabilize blood pressure. Encouraging oral fluids may not be sufficient for a confused patient, cooling blankets are more appropriate for heat stroke, and acetaminophen does not address the underlying dehydration.
A nurse plans care for a client admitted with a snakebite on the right leg. With whom should the nurse collaborate?
- A. The facility's neurologist
- B. The regional poison control center
- C. The physical therapy department
- D. A herpetologist (snake specialist)
Correct Answer: B
Rationale: For snakebites, the regional poison control center provides specialized advice on antivenom and client management. Neurologists, physical therapists, or herpetologists are not the primary resources for acute snakebite care.
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.
A nurse teaches a client who has severe allergies to prevent bug bites. Which statements should the nurse include in this client's teaching? (Select all that apply.)
- A. Consult an exterminator to control bugs in and around your home.
- B. Wear synthetic clothing that dries quickly.
- C. Use insect repellent with DEET.
- D. Wear long sleeves and pants in wooded areas.
- E. Avoid wearing bright colors or strong perfumes.
Correct Answer: A,C,D,E
Rationale: Consulting an exterminator, using DEET repellent, wearing protective clothing, and avoiding attractants like bright colors or perfumes reduce bug bite risk. Synthetic clothing drying quickly is not directly relevant to preventing bites.
A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed?
- A. I can go swimming all by myself because I am a certified lifeguard.
- B. I will not leave my toddler alone in the bathtub for even a minute.
- C. I will appoint an adult to supervise the pool at all times during a party.
- D. I will make sure that there is a phone near my pool in case of an emergency.
Correct Answer: A
Rationale: People should never swim alone, regardless of lifeguard status, due to the risk of drowning. The other statements indicate good understanding of water safety principles.