Nokea
The charge nurse is making assignments. Which client should be assigned to the most experienced nurse?
- A. The client diagnosed with a snake bite who is receiving antivenin.
- B. The client who swallowed a lye preparation and is being discharged.
- C. The client who is angry the suicide attempt did not work.
- D. The client who required skin grafting after a chemical spill.
Correct Answer: A
Rationale: Antivenin administration for snake bites requires close monitoring for anaphylaxis and dosing, best handled by an experienced nurse. Lye ingestion discharge, psychiatric issues, and grafts are less acute.
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The triage nurse in a large trauma center has been notified of an explosion in a major chemical manufacturing plant. Which action should the nurse implement first when the clients arrive at the emergency department?
- A. Triage the clients and send them to the appropriate areas.
- B. Thoroughly wash the clients with soap and water and then rinse.
- C. Remove the clients’ clothing and have them shower.
- D. Assume the clients have been decontaminated at the plant.
Correct Answer: C
Rationale: Removing contaminated clothing and showering prevents ongoing chemical exposure, the first priority. Triage follows, washing is part of decontamination, and assuming decontamination is unsafe.
The client has ingested a corrosive solution containing lye. Which intervention should the nurse implement?
- A. Administer syrup of ipecac to induce vomiting.
- B. Insert a nasogastric tube and connect to wall suction.
- C. Assess for airway compromise.
- D. Immediately administer water or milk.
Correct Answer: C
Rationale: Lye is corrosive, risking airway edema; assessing for compromise is critical. Ipecac is contraindicated, NG tubes are for non-corrosives, and water/milk may delay care.
The nurse is teaching a class about rape prevention to a group of women at a community center. Which information is not a myth about rape?
- A. Women who are raped asked for it by dressing provocatively.
- B. If a woman says no, it is a come on and she really does not mean it.
- C. Rape is an attempt to exert power and control over the client.
- D. All victims of sexual assault are women; men can’t be raped.
Correct Answer: C
Rationale: Rape is about power and control, not sexual desire, a fact. Provocative dressing, misinterpreting 'no,' and excluding male victims are myths.
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants intervention by the nurse?
- A. The UAP places a urine specimen in a biohazard bag in the hallway.
- B. The UAP uses the alcohol foam hand cleanser after removing gloves.
- C. The UAP puts soiled linen in a plastic bag in the client’s room.
- D. The UAP obtains a disposable stethoscope for a client in an isolation room.
Correct Answer: A
Rationale: Urine specimens are not biohazardous unless visibly bloody; placing in a biohazard bag is incorrect and requires intervention. Hand cleansing, linen handling, and stethoscope use are appropriate.
The client diagnosed with septicemia is receiving a broad-spectrum antibiotic. Which laboratory data require the nurse to notify the health-care provider?
- A. The client’s potassium level is 3.8 mEq/L.
- B. The urine culture indicates high sensitivity to the antibiotic.
- C. The client’s pulse oximeter reading is 94%.
- D. The culture and sensitivity is resistant to the client’s antibiotic.
Correct Answer: D
Rationale: Antibiotic resistance requires immediate HCP notification to adjust therapy. Normal potassium, sensitive cultures, and 94% SpO2 are not urgent.