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A student reports to the school nurse with complaints of stinging and burning from a wasp sting. Which intervention should the nurse implement?
- A. Grasp the stinger and pull it out.
- B. Apply a warm, moist soak to the area.
- C. Cleanse the site with alcohol.
- D. Apply an ice pack to the site.
Correct Answer: D
Rationale: An ice pack reduces pain and swelling from a wasp sting. Removing the stinger is unnecessary (wasps don’t leave stingers), warm soaks increase swelling, and alcohol is ineffective.
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The nurse is teaching a class on disaster preparedness. Which are components of an emergency operations plan (EOP)? Select all that apply.
- A. A plan for practice drills.
- B. A deactivation response.
- C. A plan for internal communication only.
- D. A preincident response.
- E. A security plan.
Correct Answer: A,B,D,E
Rationale: An EOP includes practice drills, deactivation, preincident planning, and security. Communication plans include external stakeholders, not just internal.
The ED nurse is caring for a male client admitted with carbon monoxide poisoning. Which intervention requires the nurse to notify the rapid response team?
- A. The client has expectorated black sputum.
- B. The client reports trying to kill himself.
- C. The client’s pulse oximeter reading is 94%.
- D. The client has stridor and reports dizziness.
Correct Answer: D
Rationale: Stridor indicates airway obstruction, and dizziness suggests worsening CO toxicity, requiring rapid response. Black sputum, suicidal intent, and 94% SpO2 are less acute.
The nurse working in a homeless shelter identifies an adolescent female sexually aggressive toward some of the males in the shelter. Which is the most common cause for this behavior?
- A. The client is acting in a learned behavior pattern to get attention.
- B. The client had to leave home because of promiscuous behavior.
- C. The client has a psychiatric disorder called nymphomania.
- D. The client is a prostitute and is trying to get customers.
Correct Answer: A
Rationale: Sexual aggression in adolescents often reflects learned behavior from past abuse or trauma, seeking attention or control. Promiscuity, nymphomania, or prostitution are less likely or outdated terms.
The charge nurse is making assignments. Which client should be assigned to the most experienced nurse?
- A. The client diagnosed with a snake bite who is receiving antivenin.
- B. The client who swallowed a lye preparation and is being discharged.
- C. The client who is angry the suicide attempt did not work.
- D. The client who required skin grafting after a chemical spill.
Correct Answer: A
Rationale: Antivenin administration for snake bites requires close monitoring for anaphylaxis and dosing, best handled by an experienced nurse. Lye ingestion discharge, psychiatric issues, and grafts are less acute.
The client is diagnosed with neurogenic shock. Which signs/symptoms should the nurse assess in this client?
- A. Cool, moist skin.
- B. Bradycardia.
- C. Wheezing.
- D. Decreased bowel sounds.
Correct Answer: B
Rationale: Neurogenic shock causes bradycardia due to loss of sympathetic tone. Cool, moist skin is typical of hypovolemic shock, wheezing suggests anaphylaxis, and decreased bowel sounds are non-specific.