Nokea
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.
You may also like to solve these questions
Which signs/symptoms should the nurse assess in the client who has been exposed to the anthrax bacillus via the skin?
- A. A scabby, clear fluid-filled vesicle.
- B. Edema, pruritus, and a 2-mm ulcerated vesicle.
- C. Irregular brownish-pink spots around the hairline.
- D. Tiny purple spots flush with the surface of the skin.
Correct Answer: B
Rationale: Cutaneous anthrax presents with edema, pruritus, and a small ulcerated vesicle that becomes necrotic. Scabby vesicles, brownish-pink spots, and purple spots are not typical.
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.
The nurse is caring for clients on a medical floor. Which client is most likely to experience sudden cardiac death?
- A. The 84-year-old client exhibiting uncontrolled atrial fibrillation.
- B. The 60-year-old client exhibiting asymptomatic sinus bradycardia.
- C. The 53-year-old client exhibiting ventricular fibrillation.
- D. The 65-year-old client exhibiting supraventricular tachycardia.
Correct Answer: C
Rationale: Ventricular fibrillation is a lethal arrhythmia causing sudden cardiac death if untreated. Atrial fibrillation, bradycardia, and SVT are less immediately fatal.
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 unlicensed assistive personnel (UAP) is performing cardiac compressions on an adult client during a code. Which behavior warrants immediate intervention by the nurse?
- A. The UAP has hand placement on the lower half of the sternum.
- B. The UAP performs cardiac compressions and allows for rescue breathing.
- C. The UAP depresses the sternum 0.5 to one (1) inch during compressions.
- D. The UAP asks to be relieved from performing compressions because of exhaustion.
Correct Answer: C
Rationale: Compressions should depress the sternum 2–2.4 inches; 0.5–1 inch is inadequate, requiring intervention. Correct hand placement, rescue breathing, and relief requests are appropriate.