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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.
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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 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.
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.
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 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.