Nokea
A nurse is treating a client who came to the emergency department after getting bit by a snake on their arm. After confirming the resuscitation equipment is at the bedside, which of the following actions by the nurse would be a priority?
- A. Contact Poison Control for guidance on an antivenom.
- B. Ensure the client's peripheral intravenous (IV) lines are patent.
- C. Apply a tourniquet above the snake bitten area on the arm.
- D. Assess for rash, fever, chills, nausea, vomiting, and joint pain.
Correct Answer: B
Rationale: Ensuring patent IV lines is the priority to enable rapid antivenom or fluid administration, critical for snakebite management. Contacting Poison Control (A) is secondary, tourniquets (C) are harmful, and symptom assessment (D) is important but not the immediate priority.
You may also like to solve these questions
A 29-year-old woman is concerned about her personal risk factors for malignant melanoma. She is upset because her 49-year-old sister was recently diagnosed with the disease. After gathering information about the client's history of sun exposure, the nurse's best response would be to explain that:
- A. Some melanomas have a familial component and she should seek medical advice.
- B. Her personal risk is low because most melanomas occur at age 60 or later.
- C. Her personal risk is low because melanoma does not have a familial component.
- D. She should not worry because she did not experience severe sunburn as a child.
Correct Answer: A
Rationale: Melanoma can have a familial component, and a family history increases personal risk. Seeking medical advice for screening and risk assessment is appropriate, especially given her sister's diagnosis.
Which teaching point is critical for a client with a new diagnosis of epilepsy?
- A. Avoid driving until seizures are controlled.
- B. Limit all social activities.
- C. Discontinue medications if seizures stop.
- D. Restrict fluid intake.
Correct Answer: A
Rationale: Avoiding driving until seizures are controlled is critical for safety in epilepsy management.
A client who had received 25 mL of packed red blood cells (PRBCs) has low back pain and pruritus. After stopping the infusion, the nurse should take what action next?
- A. Administer prescribed antihistamine and aspirin.
- B. Collect blood and urine samples and send to the lab.
- C. Administer prescribed diuretics.
- D. Administer prescribed vasopressors.
Correct Answer: B
Rationale: Low back pain and pruritus after 25 mL of PRBCs suggest a transfusion reaction, likely hemolytic or allergic. After stopping the infusion, the nurse should collect blood and urine samples to assess for hemolysis (e.g., free hemoglobin in plasma or urine). Antihistamines may be administered later for allergic symptoms, but lab samples are the priority. Diuretics and vasopressors are not indicated.
A client with advanced ovarian cancer takes 150 mg of long-acting morphine orally every 12 hours for abdominal pain. When the client develops a small bowel obstruction, the physician discontinues the oral morphine and begins morphine 6 mg/hour I.V. After calculating the equianalgesic conversion from oral to intravenous morphine, the nurse should:
- A. Continue the oral morphine for one more dose after the I.V. morphine is started.
- B. Contact the physician to suggest a higher equianalgesic dose of I.V. morphine.
- C. Administer the morphine I.V. as ordered.
- D. Clarify the order to recommend the initial morphine dose of 4 mg/hour.
Correct Answer: B
Rationale: The equianalgesic conversion from 150 mg oral morphine every 12 hours (300 mg/day oral) to I.V. morphine (1:3 ratio) is approximately 100 mg/day I.V., or 4.2 mg/hour. The ordered 6 mg/hour is too high, and the nurse should contact the physician to adjust the dose.
The nurse is caring for a 78-year-old male with lung cancer who is receiving chemotherapy. The client states he is not eating well but otherwise feels healthy. Which meal suggestion would be best for this client?
- A. Local health milk and strawberries.
- B. Toast, gelatin dessert, and cookies.
- C. Broiled chicken, green beans, and cottage cheese.
- D. Steak and french fries.
Correct Answer: C
Rationale: Broiled chicken, green beans, and cottage cheese provide high protein and nutrients with low fat, which is ideal for a client with poor appetite during chemotherapy to support nutrition without being heavy.