Nokea
An emergency department nurse assesses a client admitted after a lightning strike. Which assessment should the nurse complete first?
- A. Electrocardiogram (ECG)
- B. Electroencephalogram (EEG)
- C. Creatine kinase
- D. Computed tomography of head
Correct Answer: A
Rationale: Clients who survive a lightning strike can have serious myocardial injury. An ECG is the priority to assess for cardiac complications. Other assessments should be completed but are not the priority.
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A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed?
- A. I can go swimming all by myself because I am a certified lifeguard.
- B. I will not leave my toddler alone in the bathtub for even a minute.
- C. I will appoint an adult to supervise the pool at all times during a party.
- D. I will make sure that there is a phone near my pool in case of an emergency.
Correct Answer: A
Rationale: People should never swim alone, regardless of lifeguard status, due to the risk of drowning. The other statements indicate good understanding of water safety principles.
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.
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 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.
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.