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The client with a temperature of 94°F is being treated in the ED. Which intervention should the nurse implement to directly elevate the client’s temperature?
- A. Remove the client’s clothing.
- B. Place a warm air blanket over the client.
- C. Have the client change into a hospital gown.
- D. Raise the temperature in the room.
Correct Answer: B
Rationale: A warm air blanket (e.g., Bair Hugger) directly raises core temperature in hypothermia. Removing clothing, changing gowns, or room temperature are less effective.
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The client is diagnosed with neurogenic shock. Which signs/symptoms should the nurse assess in this client?
- A. Cool, moist skin.
- B. Bradycardia.
- C. Wheezing.
- D. Decreased bowel sounds.
Correct Answer: B
Rationale: Neurogenic shock causes bradycardia due to loss of sympathetic tone. Cool, moist skin is typical of hypovolemic shock, wheezing suggests anaphylaxis, and decreased bowel sounds are non-specific.
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 in a disaster is triaging the following clients. Which client should be triaged as an Expectant Category, Priority 4, and color black?
- A. The client with a sucking chest wound who is alert.
- B. The client with a head injury who is unresponsive.
- C. The client with an abdominal wound and stable vital signs.
- D. The client with a sprained ankle which may be fractured.
Correct Answer: B
Rationale: Expectant (black) category includes unresponsive clients with minimal survival chance (e.g., severe head injury). Sucking chest wounds (red), abdominal wounds (yellow), and sprains (green) are higher priority.
The nurse is providing first aid to a victim of a poisonous snake bite. Which intervention should be the nurse’s first action?
- A. Apply a tourniquet to the affected limb.
- B. Cut an 'X' across the bite and suck out the venom.
- C. Administer a corticosteroid medication.
- D. Have the client lie still and remove constrictive items.
Correct Answer: D
Rationale: Immobilizing the limb and removing constrictive items (e.g., jewelry) prevents venom spread and swelling, the first action. Tourniquets, cutting, and steroids are outdated or secondary.
The ED nurse is caring for a client diagnosed with multiple rib fractures. Which data should the nurse include in the assessment?
- A. Level of orientation to time and place.
- B. Current use and last dose of medication.
- C. Symmetrical movement of the chest.
- D. Time of last meal the client ate.
Correct Answer: C
Rationale: Symmetrical chest movement assesses for complications like pneumothorax or flail chest in rib fractures. Orientation, medications, and meal timing are secondary.