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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.
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The nurse is responding to a disaster call from home following a multivehicle motor-vehicle accident. Which action should the nurse take first?
- A. Go to the emergency department to triage the clients coming in.
- B. Assist the charge nurse to identify clients who could be discharged.
- C. Report to the command center for assignment.
- D. Pack a bag to be able to stay until the emergency is over.
Correct Answer: C
Rationale: Reporting to the command center ensures coordinated assignment per disaster protocol. Triaging, discharging, or packing are secondary.
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.
Which situation warrants the nurse obtaining information from a material safety data sheet (MSDS)?
- A. The custodian spilled a chemical solvent in the hallway.
- B. A visitor slipped and fell on the floor that had just been mopped.
- C. A bottle of antineoplastic agent broke on the client’s floor.
- D. The nurse was stuck with a contaminated needle in the client’s room.
Correct Answer: A
Rationale: MSDS provides handling and exposure information for chemical spills like solvents. Antineoplastic spills require specific protocols, and needle sticks or falls involve infection control or safety protocols, not MSDS.
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.
Which equipment must be immediately brought to the client’s bedside when a code is called for a client who has experienced a cardiac arrest?
- A. A ventilator.
- B. A crash cart.
- C. A gurney.
- D. Portable oxygen.
Correct Answer: B
Rationale: A crash cart contains defibrillator, medications, and airway equipment, essential for cardiac arrest. Ventilator, gurney, and oxygen are secondary or supportive.