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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A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable about biochemical agents, is giving directions to the travelers. Which direction should the nurse provide to the travelers?
- A. Hold their breath as much as possible.
- B. Stand up to avoid heavy exposure.
- C. Lie down to stay under the exposure.
- D. Attempt to breathe through their clothing.
Correct Answer: C
Rationale: Lying down minimizes exposure to chemical agents, which may settle lower. Breath-holding is temporary, standing increases exposure, and clothing is minimally protective.
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.
Which intervention is the most important for the intensive care unit nurse to implement when performing mouth-to-mouth resuscitation on a client who has pulseless ventricular fibrillation?
- A. Perform the jaw thrust maneuver to open the airway.
- B. Use the mouth to cover the client’s mouth and nose.
- C. Insert an oral airway prior to performing mouth to mouth.
- D. Use a pocket mouth shield to cover the client’s mouth.
Correct Answer: A
Rationale: The jaw thrust opens the airway without neck manipulation, critical in suspected trauma or codes. Covering mouth and nose, oral airways, and shields are secondary or less safe.
The nurse in the emergency department administered an intramuscular antibiotic in the left gluteal muscle to the client with pneumonia who is being discharged home. Which intervention should the nurse implement?
- A. Ask the client about drug allergies.
- B. Obtain a sterile sputum specimen.
- C. Have the client wait for 30 minutes.
- D. Place a warm washcloth on the client’s left hip.
Correct Answer: C
Rationale: Waiting 30 minutes post-antibiotic monitors for allergic reactions, critical for safety. Allergies should be checked pre-administration, sputum is diagnostic, and warm washcloths are not standard.
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.