Nokea
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.
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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 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.
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 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 teaching the client home care instructions for a reimplanted finger after a traumatic amputation. Which information should the nurse include in the teaching?
- A. Perform range-of-motion exercises weekly.
- B. Smoking may be resumed if it does not cause nausea.
- C. Protect the finger and be careful not to reinjure the finger.
- D. An elevated temperature is the only reason to call the HCP.
Correct Answer: C
Rationale: Protecting the reimplanted finger prevents reinjury, critical for healing. ROM timing varies, smoking impairs circulation, and multiple symptoms warrant HCP contact.