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The nurse is caring for a client diagnosed with septic shock who has hypotension, decreased urine output, and cool, pale skin. Which phase of septic shock is the client experiencing?
- A. The hypodynamic phase.
- B. The compensatory phase.
- C. The hyperdynamic phase.
- D. The progressive phase.
Correct Answer: A
Rationale: The hypodynamic (cold) phase of septic shock involves hypotension, low urine output, and cool, pale skin due to vasoconstriction. Compensatory is early, hyperdynamic is warm, and progressive involves organ failure.
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The nurse is working at a facility where an Ebola client has been admitted. Which action should the nurse take?
- A. Consult the nurse manager regarding the infection-control standards to follow.
- B. Resign immediately and leave the facility.
- C. Watch the television news reports to identify which station has the client.
- D. Participate in a news report about the quality of care provided at the hospital.
Correct Answer: A
Rationale: Consulting the nurse manager ensures adherence to Ebola-specific infection control (e.g., PPE, isolation). Resigning, watching news, or participating in reports are inappropriate.
The client who was abused as a child is diagnosed with post-traumatic stress disorder (PTSD). Which intervention should the nurse implement when the client is resting?
- A. Call the client’s name to awaken him or her, but don’t touch the client.
- B. Touch the client gently to let him or her know you are in the room.
- C. Enter the room as quietly as possible to not disturb the client.
- D. Do not allow the client to be awakened at all when sleeping.
Correct Answer: A
Rationale: Calling the name without touching avoids startling a PTSD client, preventing flashbacks. Touching, quiet entry, or preventing awakening may trigger or disrupt.
Which federal agency is a resource for the nurse volunteering at the American Red Cross who is on a committee to prepare the community for any type of disaster?
- A. The Joint Commission (JC).
- B. Office of Emergency Management (OEM).
- C. Department of Health and Human Services (DHHS).
- D. Metro Medical Response Systems (MMRS).
Correct Answer: B
Rationale: The OEM coordinates disaster preparedness and response, a key resource for Red Cross volunteers. JC accredits facilities, DHHS oversees health, and MMRS is local.
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.