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The charge nurse has been notified that a disaster has occurred and that all possible clients should be discharged so the floor can receive the casualties. Which client should not be discharged?
- A. The 13-year-old client who is scheduled for a tonsillectomy.
- B. The 42-year-old client scheduled for an abdominal aorta aneurysm dissection.
- C. The 76-year-old client diagnosed with a pulmonary embolus whose INR is 2.9.
- D. The 80-year-old client who is refusing to assist in activities of daily living.
Correct Answer: C
Rationale: A pulmonary embolus with INR 2.9 (therapeutic) requires ongoing anticoagulation and monitoring, precluding discharge. Tonsillectomy, aneurysm surgery, and ADL refusal are less acute.
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The client is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first?
- A. Start an IV with an 18-gauge catheter.
- B. Administer dopamine intravenous infusion.
- C. Obtain arterial blood gases (ABGs).
- D. Insert an indwelling urinary catheter.
Correct Answer: A
Rationale: Hypovolemic shock (suggested by symptoms) requires immediate IV access for fluid resuscitation. Dopamine requires IV access, ABGs are diagnostic, and urinary catheter monitors output but is secondary.
The ED nurse is caring for a client diagnosed with multiple rib fractures. Which data should the nurse include in the assessment?
- A. Level of orientation to time and place.
- B. Current use and last dose of medication.
- C. Symmetrical movement of the chest.
- D. Time of last meal the client ate.
Correct Answer: C
Rationale: Symmetrical chest movement assesses for complications like pneumothorax or flail chest in rib fractures. Orientation, medications, and meal timing are secondary.
A vat of chemicals spilled onto the client. Which action should the occupational health nurse implement first?
- A. Have the client stand under a shower while removing all clothes.
- B. Check the material safety data sheets for the antidote.
- C. Administer oxygen by nasal cannula.
- D. Collect a sample of the chemicals in the vat for analysis.
Correct Answer: A
Rationale: Removing clothes and showering decontaminates the skin, preventing further chemical absorption. MSDS, oxygen, and sampling are secondary.
During a disaster, a local news reporter comes to the emergency department requesting information about the victims. Which action is most appropriate for the nurse to implement?
- A. Have security escort the reporter off the premises.
- B. Direct the reporter to the disaster command post.
- C. Tell the reporter this is a violation of HIPAA.
- D. Request the reporter to stay out of the way.
Correct Answer: B
Rationale: Directing the reporter to the command post ensures controlled information release, adhering to HIPAA. Escorting off, citing HIPAA, or requesting to stay out are less collaborative.
The client with a temperature of 94°F is being treated in the ED. Which intervention should the nurse implement to directly elevate the client’s temperature?
- A. Remove the client’s clothing.
- B. Place a warm air blanket over the client.
- C. Have the client change into a hospital gown.
- D. Raise the temperature in the room.
Correct Answer: B
Rationale: A warm air blanket (e.g., Bair Hugger) directly raises core temperature in hypothermia. Removing clothing, changing gowns, or room temperature are less effective.