Nokea
The nurse is caring for a client with internal radiologic contamination from the fallout. The client states, 'I need to get this out of me, and then I will be done with it.' The nurse is most correct to reply which of the following?
- A. Yes, we need to assure that we clean any debris from your wound which may be contaminated.'
- B. Yes, but you may have lingering effects from the exposure to your body.'
- C. Yes, but you must also consider further exposure from contaminated food and water sources.'
- D. Yes, we need to continue to document your recovery process and further disease processes.'
Correct Answer: C
Rationale: Internal radiologic contamination occurs from exposure to fallout on the skin, in a wound, inhaled, or consumed through food and water. It is the nurse's responsibility to advise the client if further harm may occur and ways to decrease the risk.
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The nurse is evaluating a skin lesion on a client brought to the emergency department. The nurse notes characteristics of chickenpox but has the physician evaluate the lesion for which biologic disaster agent?
- A. Botulism
- B. Smallpox
- C. Rubella
- D. Anthrax
Correct Answer: B
Rationale: Smallpox may be mistaken for chickenpox due to the characteristics of the lesions. Botulism is a neurological toxin. Rubella is a communicable disease. Anthrax is a spore-forming bacterium that is inhaled or injected.
The emergency department nurse is working triage during a disaster. Why should the nurse tag a victim after assessment in a disaster situation?
- A. To know the victim's name
- B. To record any client allergies
- C. Someone else does not duplicate the assessment
- D. To record pre-disaster medical history
Correct Answer: C
Rationale: The tag is an indication that the victim has been assessed by a nurse. This ensures that the nurse or another medical person does not spend time assessing the same person twice. The tag does not contain information such as allergies or pre-disaster medical history; the person's name may not be readily available in a disaster.
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.
The nurse is instructing on bioterrorism agents. Which of the following does the nurse emphasize as an agent which is transmitted from person to person?
- A. Anthrax
- B. Botulism
- C. Smallpox
- D. Varicella
Correct Answer: C
Rationale: Smallpox is highly contagious and caused by a variola virus. Individuals infected with the botulinum toxin and anthrax are not at risk to others; there are no reports of person to person transmission. Varicella, commonly called the chickenpox, is contagious but not a bioterrorism agent.