Nokea
The nurse in a disaster is triaging the following clients. Which client should be triaged as an Expectant Category, Priority 4, and color black?
- A. The client with a sucking chest wound who is alert.
- B. The client with a head injury who is unresponsive.
- C. The client with an abdominal wound and stable vital signs.
- D. The client with a sprained ankle which may be fractured.
Correct Answer: B
Rationale: Expectant (black) category includes unresponsive clients with minimal survival chance (e.g., severe head injury). Sucking chest wounds (red), abdominal wounds (yellow), and sprains (green) are higher priority.
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Which problem is most appropriate for the nurse to identify for the client experiencing renal trauma?
- A. Infection of the renal tract.
- B. Ineffective tissue perfusion.
- C. Alteration in skin integrity.
- D. Alteration in temperature.
Correct Answer: B
Rationale: Renal trauma risks bleeding and hypoperfusion, making ineffective tissue perfusion the primary problem. Infection, skin integrity, and temperature are less immediate.
Which intervention is most important for the nurse to implement when participating in a code?
- A. Elevate the arm after administering medication.
- B. Maintain sterile technique throughout the code.
- C. Treat the client’s signs/symptoms; do not treat the monitor.
- D. Provide accurate documentation of what happened during the code.
Correct Answer: C
Rationale: Treating the client’s clinical presentation (not just monitor readings) ensures appropriate care. Arm elevation, sterile technique, and documentation are secondary during active resuscitation.
The ED nurse is caring for a client who suffered a near-drowning. Which expected outcome should the nurse include in the plan of care for this client?
- A. Maintain the client’s cardiac function.
- B. Promote a continued decrease in lung surfactant.
- C. Warm rapidly to minimize the effects of hypothermia.
- D. Keep the oxygen saturation level above 93%.
Correct Answer: D
Rationale: Maintaining SpO2 >93% ensures adequate oxygenation post-near-drowning, preventing hypoxia. Cardiac function, surfactant loss, and rapid warming are secondary or incorrect.
A gang war has resulted in 12 young males being brought to the emergency department. Which action by the nurse is priority when a gang member points a gun at a rival gang member in the trauma room?
- A. Attempt to talk to the person who has the gun.
- B. Explain to the person the police are coming.
- C. Stand between the client and the man with the gun.
- D. Get out of the line of fire and protect self.
Correct Answer: D
Rationale: Self-protection by exiting the line of fire prioritizes nurse safety, allowing for security intervention. Talking, explaining police arrival, or standing between risks harm.
The nurse writes a nursing diagnosis of 'risk for injury as a result of physical abuse by spouse' for a client. Which is an appropriate goal for this client?
- A. The client will learn not to trust anyone.
- B. The client will admit the abuse is happening and get help.
- C. The client will discuss the nurse’s suspicions with the spouse.
- D. The client will choose to stay with the spouse.
Correct Answer: B
Rationale: Admitting abuse and seeking help is a realistic goal to reduce injury risk. Distrust, confronting the spouse, or staying are unsafe or neutral.