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The CPR instructor is discussing an automated external defibrillator (AED) during class. Which statement best describes an AED?
- A. It analyzes the rhythm and shocks the client in ventricular fibrillation.
- B. The client will be able to have synchronized cardioversion with the AED.
- C. It will keep the health-care provider informed of the client’s oxygen level.
- D. The AED will perform cardiac compressions on the client.
Correct Answer: A
Rationale: An AED analyzes rhythms and delivers shocks for ventricular fibrillation or pulseless ventricular tachycardia. Cardioversion, oxygen monitoring, and compressions are not AED functions.
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The ED nurse is caring for the client who has taken an overdose of cocaine. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Evaluate the airway and breathing.
- B. Monitor the rate of intravenous fluids.
- C. Place the cardiac monitor on the client.
- D. Transfer the client to the intensive care unit.
Correct Answer: C
Rationale: Placing a cardiac monitor is a technical task delegable to UAPs. Airway evaluation, IV monitoring, and transfers require nursing judgment.
The client who was abused as a child is diagnosed with post-traumatic stress disorder (PTSD). Which intervention should the nurse implement when the client is resting?
- A. Call the client’s name to awaken him or her, but don’t touch the client.
- B. Touch the client gently to let him or her know you are in the room.
- C. Enter the room as quietly as possible to not disturb the client.
- D. Do not allow the client to be awakened at all when sleeping.
Correct Answer: A
Rationale: Calling the name without touching avoids startling a PTSD client, preventing flashbacks. Touching, quiet entry, or preventing awakening may trigger or disrupt.
A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable about biochemical agents, is giving directions to the travelers. Which direction should the nurse provide to the travelers?
- A. Hold their breath as much as possible.
- B. Stand up to avoid heavy exposure.
- C. Lie down to stay under the exposure.
- D. Attempt to breathe through their clothing.
Correct Answer: C
Rationale: Lying down minimizes exposure to chemical agents, which may settle lower. Breath-holding is temporary, standing increases exposure, and clothing is minimally protective.
The nurse is discharging a client diagnosed with accidental carbon monoxide poisoning. Which statement made by the client indicates the need for further teaching?
- A. I should install carbon monoxide detectors in my home.
- B. Having a natural bright-red color to my lips is good.
- C. You cannot smell carbon monoxide, so it can be difficult to detect.
- D. I should have my furnace checked for leaks before turning it on.
Correct Answer: B
Rationale: Bright-red lips indicate CO poisoning, not health, requiring further teaching. Detectors, odorlessness, and furnace checks are correct preventive measures.
The ED nurse is caring for a client who had a severe allergic reaction to a bee sting. Which discharge instructions should the nurse discuss with the client?
- A. Instruct the client to wear a medical identification bracelet.
- B. Apply corticosteroid cream to the site to prevent anaphylaxis.
- C. Administer epinephrine 1:10,000 intravenously every three (3) minutes.
- D. Teach the client to avoid attracting insects by wearing bright colors.
Correct Answer: A
Rationale: A medical ID bracelet alerts others to the allergy, critical for future emergencies. Topical steroids don’t prevent anaphylaxis, IV epinephrine is hospital-based, and bright colors attract insects.