Nokea
The client diagnosed with septicemia has the following health-care provider orders. Which HCP order has the highest priority?
- A. Provide clear liquid diet.
- B. Initiate IV antibiotic therapy.
- C. Obtain a STAT chest x-ray.
- D. Perform hourly glucometer checks.
Correct Answer: B
Rationale: IV antibiotics are critical in septicemia to combat infection, the primary cause. Diet, x-ray, and glucose checks are secondary to infection control.
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The triage nurse is working in the emergency department. Which client should be assessed first?
- A. The 10-year-old child whose dad thinks the child’s leg is broken.
- B. The 45-year-old male who is diaphoretic and clutching his chest.
- C. The 58-year-old female complaining of a headache and seeing spots.
- D. The 25-year-old male who cut his hand with a hunting knife.
Correct Answer: B
Rationale: Chest pain with diaphoresis suggests acute myocardial infarction, a life-threatening emergency requiring immediate assessment. Fractures, headaches, and cuts are less urgent.
The client has recently experienced a myocardial infarction. Which action by the nurse helps prevent cardiogenic shock?
- A. Monitor the client’s telemetry.
- B. Turn the client every two (2) hours.
- C. Administer oxygen via nasal cannula.
- D. Place the client in the Trendelenburg position.
Correct Answer: C
Rationale: Oxygen administration improves myocardial oxygenation, preventing cardiogenic shock post-MI. Telemetry monitors, turning prevents ulcers, and Trendelenburg is contraindicated.
The client has ingested the remaining amount of a bottle of analgesic medication. The medication comes 500 mg per capsule. Two (2) doses of two (2) capsules each have been used by another member of the family. The bottle originally had 250 capsules. How many mg of medication did the client take?
Correct Answer: 123000
Rationale: Total capsules: 250. Used: 2 doses * 2 capsules = 4 capsules. Remaining: 250 - 4 = 246 capsules. Total mg: 246 * 500 mg = 123,000 mg.
Which statement best describes the role of the medical-surgical nurse during a disaster?
- A. The nurse may be assigned to ride in the ambulance.
- B. The nurse may be assigned as a first assistant in the operating room.
- C. The nurse may be assigned to crowd control.
- D. The nurse may be assigned to the emergency department.
Correct Answer: D
Rationale: Medical-surgical nurses are often reassigned to the ED during disasters to manage increased patient loads. Ambulance, OR, and crowd control roles are less typical.
The nurse is teaching a class on bioterrorism. Which statement is the scientific rationale for designating a specific area for decontamination?
- A. Showers and privacy can be provided to the client in this area.
- B. This area isolates the clients who have been exposed to the agent.
- C. It provides a centralized area for stocking the needed supplies.
- D. It prevents secondary contamination to the health-care providers.
Correct Answer: D
Rationale: Decontamination areas prevent secondary contamination to HCPs, the primary rationale. Privacy, isolation, and supply stocking are secondary benefits.