Nokea
The ED nurse is caring for a female client with a greenstick fracture of the left forearm and multiple contusions on the face, arms, trunk, and legs. The significant other is in the treatment area with the client. Which nursing interventions should the nurse implement? List in order of priority.
- A. Determine if the client has a plan for safety.
- B. Assess the pulse, temperature, and capillary refill of the left wrist and hand.
- C. Ask the client if she feels safe in her own home.
- D. Request the significant other wait in the waiting room during the examination.
- E. Notify the social worker to consult on the case.
Correct Answer: D,C,A,B,E
Rationale: 1) Request significant other to wait (ensures private assessment); 2) Ask about safety (screens for abuse); 3) Plan for safety (addresses immediate risk); 4) Assess limb (ensures circulation); 5) Notify social worker (coordinates support).
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Which federal agency is a resource for the nurse volunteering at the American Red Cross who is on a committee to prepare the community for any type of disaster?
- A. The Joint Commission (JC).
- B. Office of Emergency Management (OEM).
- C. Department of Health and Human Services (DHHS).
- D. Metro Medical Response Systems (MMRS).
Correct Answer: B
Rationale: The OEM coordinates disaster preparedness and response, a key resource for Red Cross volunteers. JC accredits facilities, DHHS oversees health, and MMRS is local.
The nurse is caring for a client diagnosed with septic shock who has hypotension, decreased urine output, and cool, pale skin. Which phase of septic shock is the client experiencing?
- A. The hypodynamic phase.
- B. The compensatory phase.
- C. The hyperdynamic phase.
- D. The progressive phase.
Correct Answer: A
Rationale: The hypodynamic (cold) phase of septic shock involves hypotension, low urine output, and cool, pale skin due to vasoconstriction. Compensatory is early, hyperdynamic is warm, and progressive involves organ failure.
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.
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 is working at a facility where an Ebola client has been admitted. Which action should the nurse take?
- A. Consult the nurse manager regarding the infection-control standards to follow.
- B. Resign immediately and leave the facility.
- C. Watch the television news reports to identify which station has the client.
- D. Participate in a news report about the quality of care provided at the hospital.
Correct Answer: A
Rationale: Consulting the nurse manager ensures adherence to Ebola-specific infection control (e.g., PPE, isolation). Resigning, watching news, or participating in reports are inappropriate.