Nokea
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.
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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.
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 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.