Nokea
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.
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Which equipment must be immediately brought to the client’s bedside when a code is called for a client who has experienced a cardiac arrest?
- A. A ventilator.
- B. A crash cart.
- C. A gurney.
- D. Portable oxygen.
Correct Answer: B
Rationale: A crash cart contains defibrillator, medications, and airway equipment, essential for cardiac arrest. Ventilator, gurney, and oxygen are secondary or supportive.
The nurse is teaching a class on bioterrorism and is discussing personal protective equipment (PPE). Which statement is the most important fact for the nurse to share with the participants?
- A. Health-care facilities should keep masks at entry doors.
- B. The respondent should be trained in the proper use of PPE.
- C. No single combination of PPE protects against all hazards.
- D. The EPA has divided PPE into four levels of protection.
Correct Answer: B
Rationale: Proper PPE training ensures safe use, critical for protection. Mask placement, hazard specificity, and EPA levels are secondary.
The nurse finds the client unresponsive on the floor of the bathroom. Which action should the nurse implement first?
- A. Check the client for breathing.
- B. Assess the carotid artery for a pulse.
- C. Shake the client and shout.
- D. Notify the rapid response team.
Correct Answer: C
Rationale: Shaking and shouting assesses responsiveness per ACLS guidelines, the first step in a code. Breathing and pulse checks follow, and team notification is subsequent.
The female client presents to the emergency department with facial lacerations and contusions. The spouse will not leave the room during the assessment interview. Which intervention should be the nurse’s first action?
- A. Call the security guard to escort the spouse away.
- B. Discuss the injuries while the spouse is in the room.
- C. Tell the spouse the police will want to talk to him.
- D. Escort the client to the bathroom for a urine specimen.
Correct Answer: D
Rationale: Escorting the client to the bathroom provides a private opportunity to assess for abuse safely. Security, discussing injuries, or mentioning police may escalate the situation.
The nurse is discharging a client from the ED with a sutured laceration on the right knee. Which information is most important for the nurse to obtain?
- A. The date of the client’s last tetanus injection.
- B. The name of the client’s regular health-care provider.
- C. Explain the sutures must be removed in 10 to 14 days.
- D. Determine if the client has any drug or food allergies.
Correct Answer: A
Rationale: Tetanus status is critical for lacerations to prevent infection, especially if >5 years since last dose. HCP name, suture removal, and allergies are secondary.