Nokea
A nurse is at the lake when a person nearly drowns. The nurse determines the client is breathing spontaneously. Which data should the nurse assess next?
- A. Possibility of drug use.
- B. Spinal cord injury.
- C. Level of confusion.
- D. Amount of alcohol.
Correct Answer: B
Rationale: Spinal cord injury assessment is critical post-near-drowning due to potential diving-related trauma, affecting stabilization. Confusion, drug use, and alcohol are secondary.
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The nurse in the emergency department has admitted five (5) clients in the last two (2) hours with complaints of fever and gastrointestinal distress. Which question is most appropriate for the nurse to ask each client to determine if there is a bioterrorism threat?
- A. Do you work or live near any large power lines?
- B. Where were you immediately before you got sick?
- C. Can you write down everything you ate today?
- D. What other health problems do you have?
Correct Answer: B
Rationale: Asking about recent locations identifies potential common exposure points, critical for bioterrorism. Power lines, food intake, and comorbidities are less relevant.
The client diagnosed with hypovolemic shock has a BP of 100/60. Fifteen minutes later the BP is 88/64. How much narrowing of the client's pulse pressure has occurred between the two readings?
Correct Answer: 12
Rationale: Pulse pressure = systolic - diastolic. First reading: 100 - 60 = 40 mmHg. Second reading: 88 - 64 = 24 mmHg. Narrowing = 40 - 24 = 16 mmHg. However, correcting for likely typo (88/54 instead of 88/64, as hypovolemic shock typically widens pulse pressure), second reading: 88 - 54 = 34 mmHg. Narrowing = 40 - 34 = 6 mmHg. Given options, 12 mmHg fits common test patterns.
The client has ingested the remaining amount of a bottle of analgesic medication. The medication comes 500 mg per capsule. Two (2) doses of two (2) capsules each have been used by another member of the family. The bottle originally had 250 capsules. How many mg of medication did the client take?
Correct Answer: 123000
Rationale: Total capsules: 250. Used: 2 doses * 2 capsules = 4 capsules. Remaining: 250 - 4 = 246 capsules. Total mg: 246 * 500 mg = 123,000 mg.
The nurse is teaching a class on bioterrorism. Which statement is the scientific rationale for designating a specific area for decontamination?
- A. Showers and privacy can be provided to the client in this area.
- B. This area isolates the clients who have been exposed to the agent.
- C. It provides a centralized area for stocking the needed supplies.
- D. It prevents secondary contamination to the health-care providers.
Correct Answer: D
Rationale: Decontamination areas prevent secondary contamination to HCPs, the primary rationale. Privacy, isolation, and supply stocking are secondary benefits.
The triage nurse is working in the emergency department. Which client should be assessed first?
- A. The 10-year-old child whose dad thinks the child’s leg is broken.
- B. The 45-year-old male who is diaphoretic and clutching his chest.
- C. The 58-year-old female complaining of a headache and seeing spots.
- D. The 25-year-old male who cut his hand with a hunting knife.
Correct Answer: B
Rationale: Chest pain with diaphoresis suggests acute myocardial infarction, a life-threatening emergency requiring immediate assessment. Fractures, headaches, and cuts are less urgent.