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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.
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After teaching a client how to prevent altitude-related illnesses, a nurse assesses the client's understanding. Which statement indicates the client needs additional teaching?
- A. If my climbing partner can't think straight, we should descend to a lower altitude.
- B. I will ask my provider about medications to help prevent acute mountain sickness.
- C. My partner and I will plan to sleep at a higher elevation to acclimate more quickly.
- D. I will drink plenty of fluids to stay hydrated while on the mountain.
Correct Answer: C
Rationale: Sleeping at a higher elevation can worsen altitude sickness. The client should be taught to sleep at a lower elevation to acclimate safely. The other statements reflect appropriate understanding of altitude illness prevention.
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.
An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions should the nurse include? (Select all that apply.)
- A. Administer oxygen via mask or nasal cannula.
- B. Administer ibuprofen, an antipyretic medication.
- C. Apply cooling techniques until core body temperature is less than 101°F.
- D. Infuse 0.9% sodium chloride via a large-bore intravenous cannula.
- E. Obtain baseline serum electrolytes and cardiac enzymes.
Correct Answer: A,D,E
Rationale: Heat stroke requires oxygen therapy, IV fluids, and baseline lab tests. Cooling should continue until the core temperature is around 102°F, not 101°F. Antipyretics like ibuprofen are ineffective for heat stroke.
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 provider prescribes diazepam (Valium) to a client who was bitten by a black widow spider. The client asks, 'What is this medication for?' How should the nurse respond?
- A. This medication is an antivenom for this type of bite.
- B. It is to relieve muscle rigidity and spasms.
- C. It prevents respiratory difficulty from excessive secretions.
- D. This medication will prevent respiratory failure.
Correct Answer: B
Rationale: Black widow spider venom causes latrodectism, characterized by muscle rigidity and spasms. Diazepam, a muscle relaxant, relieves these symptoms. It is not an antivenom, nor does it directly prevent respiratory issues.