Nokea
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.
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The client has ingested a corrosive solution containing lye. Which intervention should the nurse implement?
- A. Administer syrup of ipecac to induce vomiting.
- B. Insert a nasogastric tube and connect to wall suction.
- C. Assess for airway compromise.
- D. Immediately administer water or milk.
Correct Answer: C
Rationale: Lye is corrosive, risking airway edema; assessing for compromise is critical. Ipecac is contraindicated, NG tubes are for non-corrosives, and water/milk may delay care.
The nurse in a disaster is triaging the following clients. Which client should be triaged as an Expectant Category, Priority 4, and color black?
- A. The client with a sucking chest wound who is alert.
- B. The client with a head injury who is unresponsive.
- C. The client with an abdominal wound and stable vital signs.
- D. The client with a sprained ankle which may be fractured.
Correct Answer: B
Rationale: Expectant (black) category includes unresponsive clients with minimal survival chance (e.g., severe head injury). Sucking chest wounds (red), abdominal wounds (yellow), and sprains (green) are higher priority.
The school nurse is caring for a child with a deep laceration. Which intervention should the nurse implement first?
- A. Clean with saline solution.
- B. Apply direct pressure.
- C. Don nonsterile gloves.
- D. Notify the child’s parents.
Correct Answer: B
Rationale: Direct pressure controls bleeding, the priority in deep lacerations. Cleaning, gloves, and parental notification follow hemostasis.
A gang war has resulted in 12 young males being brought to the emergency department. Which action by the nurse is priority when a gang member points a gun at a rival gang member in the trauma room?
- A. Attempt to talk to the person who has the gun.
- B. Explain to the person the police are coming.
- C. Stand between the client and the man with the gun.
- D. Get out of the line of fire and protect self.
Correct Answer: D
Rationale: Self-protection by exiting the line of fire prioritizes nurse safety, allowing for security intervention. Talking, explaining police arrival, or standing between risks harm.
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.