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 ED nurse is completing the initial assessment on a client who becomes unresponsive. Which intervention should the nurse implement first?
- A. Assess the rate and site of the intravenous fluid.
- B. Administer an ampule of sodium bicarbonate.
- C. Assess the cardiac rhythm shown on the monitor.
- D. Prepare to cardiovert the client into sinus rhythm.
Correct Answer: C
Rationale: Assessing the cardiac rhythm determines the cause of unresponsiveness (e.g., arrhythmia), guiding ACLS interventions. IV checks, bicarbonate, and cardioversion follow.
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.
The charge nurse has been notified that a disaster has occurred and that all possible clients should be discharged so the floor can receive the casualties. Which client should not be discharged?
- A. The 13-year-old client who is scheduled for a tonsillectomy.
- B. The 42-year-old client scheduled for an abdominal aorta aneurysm dissection.
- C. The 76-year-old client diagnosed with a pulmonary embolus whose INR is 2.9.
- D. The 80-year-old client who is refusing to assist in activities of daily living.
Correct Answer: C
Rationale: A pulmonary embolus with INR 2.9 (therapeutic) requires ongoing anticoagulation and monitoring, precluding discharge. Tonsillectomy, aneurysm surgery, and ADL refusal are less acute.
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.
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants intervention by the nurse?
- A. The UAP places a urine specimen in a biohazard bag in the hallway.
- B. The UAP uses the alcohol foam hand cleanser after removing gloves.
- C. The UAP puts soiled linen in a plastic bag in the client’s room.
- D. The UAP obtains a disposable stethoscope for a client in an isolation room.
Correct Answer: A
Rationale: Urine specimens are not biohazardous unless visibly bloody; placing in a biohazard bag is incorrect and requires intervention. Hand cleansing, linen handling, and stethoscope use are appropriate.