Nokea
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.
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The occupational health nurse is called to the scene of a traumatic amputation of a finger. Which intervention should the nurse implement prior to sending the client to the ED? Select all that apply.
- A. Rinse the amputated finger with sterile normal saline.
- B. Place the amputated finger in a sealed and watertight plastic bag.
- C. Place the amputated finger into iced saline solution.
- D. Wrap the amputated finger in saline-moistened gauze dressings.
- E. Replace the amputated finger on the hand and wrap with gauze.
Correct Answer: A,B,D
Rationale: Rinsing with saline, wrapping in moist gauze, and sealing in a plastic bag preserve the amputated finger for reimplantation. Iced saline damages tissue, and replacing on the hand is incorrect.
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 Tourniquets, cutting, and steroids are outdated or secondary.
A student reports to the school nurse with complaints of stinging and burning from a wasp sting. Which intervention should the nurse implement?
- A. Grasp the stinger and pull it out.
- B. Apply a warm, moist soak to the area.
- C. Cleanse the site with alcohol.
- D. Apply an ice pack to the site.
Correct Answer: D
Rationale: An ice pack reduces pain and swelling from a wasp sting. Removing the stinger is unnecessary (wasps don’t leave stingers), warm soaks increase swelling, and alcohol is ineffective.
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.
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.