Nokea
The ED receives a client involved in a motor-vehicle accident. The nurse notes a large hematoma on the right flank. Which intervention should the nurse implement first?
- A. Insert an indwelling urinary catheter.
- B. Take the vital signs every 15 minutes.
- C. Monitor the skin turgor every hour.
- D. Mark the edges of the bruised area.
Correct Answer: B
Rationale: Frequent vital signs assess for hypovolemia from potential internal bleeding (flank hematoma suggests renal or retroperitoneal injury). Catheter, skin turgor, and marking are secondary.
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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 triage nurse has placed a disaster tag on the client. Which action warrants immediate intervention by the nurse?
- A. The nurse documents the tag number in the disaster log.
- B. The unlicensed assistive personnel documents vital signs on the tag.
- C. The health-care provider removes the tag to examine the limb.
- D. The LPN securely attaches the tag to the client’s foot.
Correct Answer: C
Rationale: Removing the disaster tag disrupts identification and tracking, requiring intervention. Documentation, vital signs, and attachment are appropriate.
According to the North Atlantic Treaty Organization (NATO) triage system, which situation is considered a level red (Priority 1)?
- A. Injuries are extensive and chances of survival are unlikely.
- B. Injuries are minor and treatment can be delayed hours to days.
- C. Injuries are significant but can wait hours without threat to life or limb.
- D. Injuries are life threatening but survivable with minimal interventions.
Correct Answer: D
Rationale: NATO red (Priority 1) indicates life-threatening injuries survivable with immediate intervention (e.g., tension pneumothorax). Extensive injuries are black, minor are green, and significant but delayed are yellow.
The nurse is assessing the client who suffered a near-drowning event. Which data require immediate intervention?
- A. The onset of pink, frothy sputum.
- B. An oral temperature of 97°F.
- C. An alcohol level of 100 mg/dL.
- D. A heart rate of 100 beats/min.
Correct Answer: A
Rationale: Pink, frothy sputum indicates pulmonary edema, a life-threatening complication requiring immediate intervention. Normal temperature, alcohol levels, and tachycardia are less urgent.
The parents bring their toddler to the ED in a panic. The parents state the child had been playing in the kitchen and got into some cleaning agents and swallowed an unknown quantity of the agents. Which health-care agency should the nurse contact at this time?
- A. Child Protective Services (CPS).
- B. The local police department.
- C. The Department of Health.
- D. The Poison Control Center.
Correct Answer: D
Rationale: The Poison Control Center provides immediate guidance on ingested toxins, critical for treatment. CPS, police, and health departments are secondary.