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The male client presents to the emergency department stating he vomited a 'large' amount of bright red blood. Which should the nurse implement first?
- A. Start an intravenous line with an 18-gauge needle.
- B. Have the UAP take the client’s vital signs.
- C. Ask the client to provide a stool specimen for blood.
- D. Send the client to radiology for an abdominal CT scan.
Correct Answer: A
Rationale: Hematemesis suggests GI bleeding, requiring immediate IV access for fluids or blood. Vital signs, stool specimens, and CT scans follow stabilization.
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The father of a child brought to the emergency department is yelling at the staff and obviously intoxicated. Which approach should the nurse take with the father?
- A. Talk to the father in a calm and low voice.
- B. Tell the father to wait in the waiting room.
- C. Notify the child’s mother to come to the ED.
- D. Call the police department to come and arrest him.
Correct Answer: A
Rationale: A calm, low voice de-escalates the situation, promoting safety. Waiting room relocation, notifying the mother, or police involvement may escalate or delay resolution.
The 84-year-old female client is admitted with multiple burn marks on the torso and under the breasts along with contusions in various stages of healing. When questioned by the nurse, the woman denies any problems have occurred. The woman lives with her son and does the housework. Which is the most probable reason the woman denies being abused?
- A. There has not been any abuse to report.
- B. The client is ashamed to admit being abused.
- C. The client has Alzheimer’s disease and can’t remember.
- D. The client has engaged in consensual sex.
Correct Answer: B
Rationale: Shame often leads elderly abuse victims to deny abuse, especially when dependent on the abuser (e.g., son). Lack of abuse is unlikely given findings, Alzheimer’s is speculative, and sex is unrelated.
The nursing administrator responds to a code situation. When assessing the situation, which role must the administrator ensure is performed for legal purposes and continuity of care of the client?
- A. A person is ventilating with an Ambu bag.
- B. A person is performing chest compressions correctly.
- C. A person is administering medications as ordered.
- D. A person is keeping an accurate record of the code.
Correct Answer: D
Rationale: Accurate code documentation is critical for legal accountability and continuity of care. Ventilation, compressions, and medications are clinical priorities but less legally binding.
The nurse is caring for a client in the prodromal phase of radiation exposure. Which signs/symptoms should the nurse assess in the client?
- A. Anemia, leukopenia, and thrombocytopenia.
- B. Sudden fever, chills, and enlarged lymph nodes.
- C. Nausea, vomiting, and diarrhea.
- D. Flaccid paralysis, diplopia, and dysphagia.
Correct Answer: C
Rationale: The prodromal phase of radiation exposure involves nausea, vomiting, and diarrhea due to cellular damage. Hematologic effects occur later, fever suggests infection, and paralysis suggests botulism.
Which signs/symptoms should the nurse assess in the client who has been exposed to the anthrax bacillus via the skin?
- A. A scabby, clear fluid-filled vesicle.
- B. Edema, pruritus, and a 2-mm ulcerated vesicle.
- C. Irregular brownish-pink spots around the hairline.
- D. Tiny purple spots flush with the surface of the skin.
Correct Answer: B
Rationale: Cutaneous anthrax presents with edema, pruritus, and a small ulcerated vesicle that becomes necrotic. Scabby vesicles, brownish-pink spots, and purple spots are not typical.