Nokea
The nurse is caring for a client exposed to a blistering agent. While the nurse is quickly decontaminating the client by showering and bagging all client clothing, what is the nurse simultaneously assessing for?
- A. Neurological compromise
- B. Respiratory compromise
- C. Cardiovascular compromise
- D. Sensory neglect
Correct Answer: B
Rationale: A person exposed to a blistering agent or vesicant must be decontaminated immediately, with clothing removed and bagged. Irrigation of the victim's eyes and application of topical analgesia, antibiotics, and lubricants to the skin occur. Simultaneously, the nurse is assessing the respiratory system for airway obstruction because blisters from inhaled toxics can swell obstructing respiratory passages.
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Which isolation category should the nurse use to guide care when caring for a client with anthrax?
- A. Standard precautions
- B. Droplet precautions
- C. Airborne precautions
- D. Contact precautions
Correct Answer: A
Rationale: Standard precautions, measures for reducing the risk of transmitting pathogens, are sufficient for caring for clients infected with anthrax. These precautions are for all patients being cared for in the hospital. Droplet, airborne, and contact precautions initiate additional measures beyond those for standard precautions.
The nurse educator is preparing a presentation about the indicators of chemical terrorism. The nurse educator would include which indicator(s) in the presentation? Select all that apply.
- A. Fog-like or low-lying cloud in the atmosphere
- B. Numerous dead animals and birds
- C. Increase in temperature in area of the event
- D. Strong wind in area of the event
- E. Unexplained odor atypical for the location
Correct Answer: A,B,E
Rationale: The indicators that the nurse educator would include in the presentation are fog-like or low-lying cloud in the atmosphere, numerous dead animals and birds, and unexplained odor atypical for the location. The temperature in the area would not increase after a chemical event. There would be no wind associated with a chemical event.
The nurse is caring for a client affected by a nerve agent. The nurse quickly gives a tutorial on the neurotransmitters and nervous system affected. Which couplet is most correct?
- A. Acetylcholine, parasympathetic nervous system
- B. Serotonin, sympathetic nervous system
- C. Norepinephrine, sympathetic nervous system
- D. Dopamine, parasympathetic nervous system
Correct Answer: A
Rationale: Nerve agents cause fatal consequences by inhibiting acetyl cholinesterase. Acetyl cholinesterase is an enzyme that inactivates acetylcholine, a neurotransmitter of the parasympathetic nervous system. No other option is correct.
The nurse is caring for a client diagnosed with botulism. Which medication classification does the nurse anticipate?
- A. An antibiotic
- B. An anti-inflammatory
- C. Antipyretics
- D. Antitoxins
Correct Answer: D
Rationale: Botulism is treated with antitoxins to neutralize the botulinum toxin. Antibiotics are not effective against botulism, as it is caused by a toxin, not a bacterial infection. Anti-inflammatories and antipyretics are not indicated for botulism treatment.
The student nurse is working with a nurse manager at a hospital when a disaster drill is announced over the hospital P.A. system. The nurse manager asks the nursing student what color triage tag is used for clients who have life threatening, but survivable conditions, if rapid medical attention is provided. What color is the triage tag for these clients?
- A. Red
- B. Yellow
- C. Green
- D. Black
Correct Answer: A
Rationale: The nurse is asking about clients that are labeled immediate when the clients suffer with life threatening, but survivable conditions, if rapid medical attention is provided. Immediate clients are given a red triage tag. Clients with yellow triage tags are labeled delayed, and have injuries serious but stable enough to survive if treatment is delayed 6-8 hours. Clients with green triage tags are labeled minimal, and have injuries that are minor and can wait longer to be addressed. Clients with black triage tags are labeled expectant, and are expected to die.