Nokea
The ED nurse is caring for the client who has taken an overdose of cocaine. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Evaluate the airway and breathing.
- B. Monitor the rate of intravenous fluids.
- C. Place the cardiac monitor on the client.
- D. Transfer the client to the intensive care unit.
Correct Answer: C
Rationale: Placing a cardiac monitor is a technical task delegable to UAPs. Airway evaluation, IV monitoring, and transfers require nursing judgment.
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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.
The nurse is discharging a client diagnosed with accidental carbon monoxide poisoning. Which statement made by the client indicates the need for further teaching?
- A. I should install carbon monoxide detectors in my home.
- B. Having a natural bright-red color to my lips is good.
- C. You cannot smell carbon monoxide, so it can be difficult to detect.
- D. I should have my furnace checked for leaks before turning it on.
Correct Answer: B
Rationale: Bright-red lips indicate CO poisoning, not health, requiring further teaching. Detectors, odorlessness, and furnace checks are correct preventive measures.
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.
A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable about biochemical agents, is giving directions to the travelers. Which direction should the nurse provide to the travelers?
- A. Hold their breath as much as possible.
- B. Stand up to avoid heavy exposure.
- C. Lie down to stay under the exposure.
- D. Attempt to breathe through their clothing.
Correct Answer: C
Rationale: Lying down minimizes exposure to chemical agents, which may settle lower. Breath-holding is temporary, standing increases exposure, and clothing is minimally protective.