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The client has been brought to the ED by ambulance following a motor-vehicle accident with a flail chest, an intravenous line, and a Heimlich valve. Which intervention should the nurse implement first?
- A. Start a large-bore intravenous access.
- B. Request a portable chest x-ray.
- C. Prepare to insert chest tubes.
- D. Assess the cardiac rhythm on the monitor.
Correct Answer: C
Rationale: A flail chest with a Heimlich valve indicates a pneumothorax; preparing for chest tube insertion stabilizes breathing, the priority. Additional IVs, x-rays, and cardiac monitoring follow.
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A nurse is at the lake when a person nearly drowns. The nurse determines the client is breathing spontaneously. Which data should the nurse assess next?
- A. Possibility of drug use.
- B. Spinal cord injury.
- C. Level of confusion.
- D. Amount of alcohol.
Correct Answer: B
Rationale: Spinal cord injury assessment is critical post-near-drowning due to potential diving-related trauma, affecting stabilization. Confusion, drug use, and alcohol are secondary.
The male client presents to the emergency department stating he vomited a 'large' amount of bright red blood. Which should the nurse implement first?
- A. Start an intravenous line with an 18-gauge needle.
- B. Have the UAP take the client’s vital signs.
- C. Ask the client to provide a stool specimen for blood.
- D. Send the client to radiology for an abdominal CT scan.
Correct Answer: A
Rationale: Hematemesis suggests GI bleeding, requiring immediate IV access for fluids or blood. Vital signs, stool specimens, and CT scans follow stabilization.
Which expected outcome is priority for the nurse who is caring for a client with chest trauma from a gunshot injury?
- A. The client will have an absence of pain.
- B. The client will maintain a BP of 90/60.
- C. The client will have symmetrical chest expansion.
- D. The client will maintain urine output of 30 mL/hr.
Correct Answer: C
Rationale: Symmetrical chest expansion ensures adequate ventilation, critical in chest trauma to prevent pneumothorax or hemothorax. Pain, low BP, and urine output are secondary.
The nurse is caring for a client in the prodromal phase of radiation exposure. Which signs/symptoms should the nurse assess in the client?
- A. Anemia, leukopenia, and thrombocytopenia.
- B. Sudden fever, chills, and enlarged lymph nodes.
- C. Nausea, vomiting, and diarrhea.
- D. Flaccid paralysis, diplopia, and dysphagia.
Correct Answer: C
Rationale: The prodromal phase of radiation exposure involves nausea, vomiting, and diarrhea due to cellular damage. Hematologic effects occur later, fever suggests infection, and paralysis suggests botulism.
The charge nurse of the medical-surgical unit secured the crash cart during the code. Which intervention should the charge nurse implement after transferring the client to the intensive care unit?
- A. Reassign the clients on the floor because one is now gone.
- B. Call the family of the client who coded and let them know of the transfer.
- C. Make sure the crash cart is restocked.
- D. Hold a unit meeting to determine if anything could have been done differently during the code.
Correct Answer: C
Rationale: Restocking the crash cart ensures readiness for future emergencies, a priority post-code. Reassignment, family calls, and meetings are secondary.