Nokea
The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect?
- A. Cardiogenic shock.
- B. Hypovolemic shock.
- C. Neurogenic shock.
- D. Septic shock.
Correct Answer: B
Rationale: NSAID-induced gastrointestinal bleeding can cause hypovolemic shock, indicated by tachycardia, hypotension, and pale, clammy skin. Cardiogenic involves cardiac failure, neurogenic involves bradycardia, and septic involves fever.
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The male client was found in a parked car with the motor running. The paramedic brought the client to the ED with complaints of a headache, nausea, and dizziness and the client is unable to recall his name or address. On assessment, the nurse notes the buccal mucosa is a cherry-red color. Which intervention should the nurse implement first?
- A. Check the client’s oxygenation level with a pulse oximeter.
- B. Apply oxygen via nasal cannula at 100%.
- C. Obtain a psychiatric consult to determine if this was a suicide attempt.
- D. Prepare the client for transfer to a facility with a hyperbaric chamber.
Correct Answer: B
Rationale: Cherry-red mucosa suggests carbon monoxide (CO) poisoning; 100% oxygen via non-rebreather mask is the first intervention to displace CO. Pulse oximetry is unreliable, psychiatric consults are secondary, and hyperbaric transfer follows initial stabilization.
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.
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 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.
The client presents to the ED with acute vomiting after eating at a fast-food restaurant. There has not been any diarrhea. The nurse suspects botulism poisoning. Which nursing problem is the highest priority for this client?
- A. Fluid volume loss.
- B. Risk for respiratory paralysis.
- C. Abdominal pain.
- D. Anxiety.
Correct Answer: B
Rationale: Botulism causes progressive paralysis, including respiratory muscles, making respiratory paralysis the highest priority. Fluid loss, pain, and anxiety are secondary.