Nokea
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.
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The ED nurse is completing the initial assessment on a client who becomes unresponsive. Which intervention should the nurse implement first?
- A. Assess the rate and site of the intravenous fluid.
- B. Administer an ampule of sodium bicarbonate.
- C. Assess the cardiac rhythm shown on the monitor.
- D. Prepare to cardiovert the client into sinus rhythm.
Correct Answer: C
Rationale: Assessing the cardiac rhythm determines the cause of unresponsiveness (e.g., arrhythmia), guiding ACLS interventions. IV checks, bicarbonate, and cardioversion follow.
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.
Which intervention is most important for the nurse to implement when participating in a code?
- A. Elevate the arm after administering medication.
- B. Maintain sterile technique throughout the code.
- C. Treat the client’s signs/symptoms; do not treat the monitor.
- D. Provide accurate documentation of what happened during the code.
Correct Answer: C
Rationale: Treating the client’s clinical presentation (not just monitor readings) ensures appropriate care. Arm elevation, sterile technique, and documentation are secondary during active resuscitation.
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.
Which cultural issues should the nurse consider when caring for clients during a bioterrorism attack? Select all that apply.
- A. Language difficulties.
- B. Religious practices.
- C. Prayer times for the people.
- D. Rituals for handling the dead.
- E. Keeping the family in the designated area.
Correct Answer: A,B,C,D
Rationale: Language, religious practices, prayer times, and death rituals affect care delivery in bioterrorism scenarios. Family containment is logistical, not cultural.