Nokea
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.
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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 nurse teaches a community class about ways to decrease the risk of lightning injuries. Which instructions should the nurse include? (Select all that apply.)
- A. Seek shelter in a building or enclosed vehicle.
- B. Hide under a tall tree.
- C. Do not take a bath or shower.
- D. Turn off the television.
- E. Remove all body piercings.
- F. Put down golf clubs or gardening tools.
Correct Answer: A,C,D,F
Rationale: Seeking shelter, avoiding water, turning off electronics, and putting down conductive tools reduce lightning injury risk. Hiding under a tall tree increases risk, and body piercings do not significantly affect lightning strike likelihood.
A nurse is teaching a wilderness survival class. Which statements should the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.)
- A. Wear synthetic clothing instead of cotton to keep your skin dry.
- B. Drink plenty of fluids. Brandy can be used to keep your body warm.
- C. Remove your hat when exercising to prevent the loss of heat.
- D. Layer clothing to trap heat effectively.
- E. Know your physical limits. Come in out of the cold when limits are reached.
Correct Answer: A,D,E
Rationale: Synthetic clothing wicks moisture, layering traps heat, and knowing physical limits prevents overexposure. Alcohol like brandy causes heat loss, and removing a hat during exercise increases heat loss, both of which are incorrect.
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.
A nurse plans care for a client admitted with a snakebite on the right leg. With whom should the nurse collaborate?
- A. The facility's neurologist
- B. The regional poison control center
- C. The physical therapy department
- D. A herpetologist (snake specialist)
Correct Answer: B
Rationale: For snakebites, the regional poison control center provides specialized advice on antivenom and client management. Neurologists, physical therapists, or herpetologists are not the primary resources for acute snakebite care.