Nokea
The ED nurse is caring for a client who suffered a near-drowning. Which expected outcome should the nurse include in the plan of care for this client?
- A. Maintain the client’s cardiac function.
- B. Promote a continued decrease in lung surfactant.
- C. Warm rapidly to minimize the effects of hypothermia.
- D. Keep the oxygen saturation level above 93%.
Correct Answer: D
Rationale: Maintaining SpO2 >93% ensures adequate oxygenation post-near-drowning, preventing hypoxia. Cardiac function, surfactant loss, and rapid warming are secondary or incorrect.
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The triage nurse in a large trauma center has been notified of an explosion in a major chemical manufacturing plant. Which action should the nurse implement first when the clients arrive at the emergency department?
- A. Triage the clients and send them to the appropriate areas.
- B. Thoroughly wash the clients with soap and water and then rinse.
- C. Remove the clients’ clothing and have them shower.
- D. Assume the clients have been decontaminated at the plant.
Correct Answer: C
Rationale: Removing contaminated clothing and showering prevents ongoing chemical exposure, the first priority. Triage follows, washing is part of decontamination, and assuming decontamination is unsafe.
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 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.
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 client in a code is now in ventricular bigeminy. The HCP orders a lidocaine drip at three (3) mg/min. The lidocaine comes prepackaged with two (2) grams of lidocaine in 500 mL of D5W. At which rate will the nurse set the infusion pump?
Correct Answer: 45
Rationale: Lidocaine concentration: 2 g = 2000 mg in 500 mL = 4 mg/mL. Dose: 3 mg/min. Rate = (3 mg/min) / (4 mg/mL) = 0.75 mL/min = 45 mL/hour (0.75 * 60). Pump set to 45 mL/hour.