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A nurse is triaging victims of a multiple motor-vehicle crash. The nurse assesses a client trapped under a car who is apneic and has a weak pulse at 120/min. After repositioning his upper airway, the client remains apneic. Which of the following actions should the nurse take?
- A. Place a black tag on the client’s upper body and attempt to help the next client in need.
- B. Reposition the client’s upper airway a second time before assessing his respirations.
- C. Start CPR.
- D. Place a red tag on the client’s upper body and obtain immediate help from other personnel.
Correct Answer: A
Rationale: The correct answer is A: Place a black tag on the client’s upper body and attempt to help the next client in need. In this scenario, the client is apneic despite repositioning the airway and has a weak pulse. The client's condition falls under "expectant" during triage, indicated by a black tag. The nurse should prioritize helping those who have a higher chance of survival first. Placing a black tag and moving on to assist others is essential to maximize the number of lives saved in a mass casualty event. Starting CPR (choice C) may be futile if the client is trapped under a car with severe injuries. Choice B, repositioning the airway again, is unlikely to change the client's apneic status. Choice D, placing a red tag, is incorrect as this tag is typically used for immediate care cases.
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A client is to receive enoxaparin 30 mg subcutaneously. Available is enoxaparin 40 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.8
Rationale: To calculate the mL of enoxaparin needed, divide the desired dose (30 mg) by the concentration (40 mg/mL): 30 mg / 40 mg/mL = 0.75 mL. Since the answer should be rounded to the nearest tenth, 0.75 rounds up to 0.8 mL. Therefore, the correct answer is 0.8 mL.
Choice A (0.5 mL) is incorrect as it is not the result of the calculation. Choices B, C, D, E, F, and G are also incorrect as they do not match the correct answer derived from the calculation.
A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child’s appendix is perforated?
- A. Sudden decrease in abdominal pain.
- B. Absence of Rovsing’s sign.
- C. Low-grade fever.
- D. Rigid abdomen.
Correct Answer: A
Rationale: The correct answer is A: Sudden decrease in abdominal pain. A sudden decrease in abdominal pain can indicate a perforated appendix due to the release of pressure and inflammation. This sudden relief occurs when the appendix ruptures, causing the abdominal pain to subside temporarily. This is a critical sign that the appendix has perforated and requires immediate medical attention. The other choices are incorrect because: B: Absence of Rovsing’s sign is not specific to a perforated appendix. C: Low-grade fever is commonly seen in uncomplicated appendicitis and may not necessarily indicate perforation. D: A rigid abdomen is a sign of peritonitis, which can occur with a perforated appendix, but it is not as specific as the sudden decrease in pain.
A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
- A. Inspect the abdomen for skin integrity.
- B. Ask the client about having a history of abdominal pain.
- C. Auscultate the abdomen for bowel sounds.
- D. Percuss the abdomen in each of the four quadrants.
- E. Palpate the abdomen gently for tenderness.
Correct Answer: A,B,C,D,E
Rationale: Action to Take: A, B; Potential Condition: None; Parameter to Monitor: C, E.
Rationale:
1. Inspecting for skin integrity (A) allows the nurse to assess for any visible abnormalities or lesions.
2. Asking about abdominal pain history (B) provides insight into potential underlying conditions.
3. Auscultating for bowel sounds (C) helps assess gastrointestinal motility and function.
4. Percussing the abdomen (D) helps identify areas of abnormal fluid or gas accumulation.
5. Palpating for tenderness (E) assesses for pain or masses in the abdomen.
Summary:
- Not inspecting the abdomen (A) could miss skin abnormalities.
- Not asking about abdominal pain history (B) could overlook important medical information.
- Skipping auscultation (C) could lead to missing crucial gastrointestinal assessment.
- Not percussing (D) may result in overlooking potential abdominal issues.
- Omitting palpation (E) could miss detecting tend
A nurse is teaching a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client needs further instruction?
- A. A high concentration of carbon monoxide can cause death.
- B. I should purchase a carbon monoxide detector for my home.
- C. Breathing in carbon monoxide can cause headaches and nausea.
- D. I can detect the presence of carbon monoxide by a metallic odor.
Correct Answer: D
Rationale: The correct answer is D. Carbon monoxide is odorless, colorless, and tasteless, so it cannot be detected by a metallic odor. This is a common misconception that needs to be corrected. A: True, high concentrations can be fatal. B: Correct, a detector is essential for safety. C: True, common symptoms of CO poisoning. In summary, D is incorrect because carbon monoxide does not have a metallic odor, unlike the other options which are all accurate statements regarding carbon monoxide poisoning.
A nurse is preparing a response protocol for botulism as a bioterrorism agent. The nurse should prepare the protocol based on which of the following information? (Select all that apply.)
- A. Botulism is acquired through direct contact with an infected person.
- B. Notify the Centers for Disease Control and Prevention (CDC) when more than three cases are confirmed.
- C. Botulism can produce paralysis within 12 to 72 hours following exposure.
- D. Vomiting and diarrhea are expected findings following exposure.
- E. Botulism is a toxin found in castor beans.
Correct Answer: C,D
Rationale: The correct answers are C and D. Choice C is correct because botulism can indeed produce paralysis within 12 to 72 hours following exposure. This is crucial information for early detection and treatment. Choice D is also correct because vomiting and diarrhea are not typical symptoms of botulism. The toxin primarily affects the nervous system, leading to symptoms such as muscle weakness and paralysis. Choices A, B, and E are incorrect. Botulism is not acquired through direct contact with an infected person (A), the CDC should be notified immediately upon suspicion of botulism, not after a certain number of cases (B), and botulism toxin is not found in castor beans (E).