Nokea
The ED nurse is caring for a male client admitted with carbon monoxide poisoning. Which intervention requires the nurse to notify the rapid response team?
- A. The client has expectorated black sputum.
- B. The client reports trying to kill himself.
- C. The client’s pulse oximeter reading is 94%.
- D. The client has stridor and reports dizziness.
Correct Answer: D
Rationale: Stridor indicates airway obstruction, and dizziness suggests worsening CO toxicity, requiring rapid response. Black sputum, suicidal intent, and 94% SpO2 are less acute.
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The client has expired secondary to smallpox. Which information about funeral arrangements is most important for the nurse to provide to the client’s family?
- A. The client should be cremated.
- B. Suggest an open casket funeral.
- C. Bury the client within 24 hours.
- D. Notify the public health department.
Correct Answer: D
Rationale: Notifying the public health department is critical for smallpox, a highly contagious disease, to ensure containment. Cremation, open caskets, and rapid burial are secondary.
The health-care facility has been notified an alleged inhalation anthrax exposure has occurred at the local post office. Which category of personal protective equipment (PPE) should the response team wear?
- A. Level A.
- B. Level B.
- C. Level C.
- D. Level D.
Correct Answer: C
Rationale: Level C PPE (respirator and protective suit) is appropriate for inhalation anthrax, balancing protection and mobility. Level A is for highest risk, Level B for chemical hazards, and Level D is minimal.
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.
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 nurse working in a homeless shelter identifies an adolescent female sexually aggressive toward some of the males in the shelter. Which is the most common cause for this behavior?
- A. The client is acting in a learned behavior pattern to get attention.
- B. The client had to leave home because of promiscuous behavior.
- C. The client has a psychiatric disorder called nymphomania.
- D. The client is a prostitute and is trying to get customers.
Correct Answer: A
Rationale: Sexual aggression in adolescents often reflects learned behavior from past abuse or trauma, seeking attention or control. Promiscuity, nymphomania, or prostitution are less likely or outdated terms.