Nokea
A provider prescribes a rewarming bath for a client who presents with partial-thickness frostbite. Which action should the nurse take prior to starting this treatment?
- A. Administer intravenous morphine.
- B. Wrap the limb with a compression dressing.
- C. Massage the frostbitten areas.
- D. Assess the limb for compartment syndrome.
Correct Answer: A
Rationale: Rapid rewarming in a water bath is recommended for frostbite, but it causes severe pain. Administering IV morphine prior to treatment is essential for pain management. Wrapping with a compression dressing or massaging the area can cause further tissue damage, and assessing for compartment syndrome is not the priority before rewarming.
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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.
A provider prescribes Crotalidae Polyvalent Immune Fab (CroFab) for a client who is admitted after being bitten by a pit viper snake. Which assessment should the nurse complete prior to administering this medication?
- A. Inspect the temperature for signs of fever.
- B. Check the client's creatine kinase level.
- C. Ask about allergies to pineapple or papaya.
- D. Inspect the skin for signs of internal hives.
Correct Answer: C
Rationale: CroFab is an antivenom for pit viper bites. Assessing for allergies to pineapple or papaya (due to bromelain and papain components) is critical to prevent hypersensitivity reactions. Other assessments are relevant but not the priority before administration.
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 admitted with a brown recluse spider bite. Which priority assessment should the nurse perform to identify complications of this bite?
- A. Ask the client about pruritus at the bite site.
- B. Inspect the bite site for a purple center.
- C. Assess the extremity for redness and swelling.
- D. Monitor the client's temperature every 4 hours.
Correct Answer: D
Rationale: Fever and chills indicate systemic toxicity from a brown recluse spider bite, which can lead to severe complications like hemolytic reactions or kidney failure. Monitoring temperature is the priority. Other assessments are relevant but not as critical for detecting systemic complications.
While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. Which action should the nurse take first?
- A. Deliver rescue breaths.
- B. Wrap the client in dry blankets.
- C. Assess for signs of bleeding.
- D. Check for a cerebral pulse.
Correct Answer: A
Rationale: Agonal breathing indicates inadequate ventilation. Delivering rescue breaths is the priority to restore airway and ventilation. Wrapping in blankets or assessing bleeding are secondary, and cerebral pulse is not a standard assessment.