Nokea
The nurse is discharging a client diagnosed with accidental carbon monoxide poisoning. Which statement made by the client indicates the need for further teaching?
- A. I should install carbon monoxide detectors in my home.
- B. Having a natural bright-red color to my lips is good.
- C. You cannot smell carbon monoxide, so it can be difficult to detect.
- D. I should have my furnace checked for leaks before turning it on.
Correct Answer: B
Rationale: Bright-red lips indicate CO poisoning, not health, requiring further teaching. Detectors, odorlessness, and furnace checks are correct preventive measures.
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The nurse in the emergency department administered an intramuscular antibiotic in the left gluteal muscle to the client with pneumonia who is being discharged home. Which intervention should the nurse implement?
- A. Ask the client about drug allergies.
- B. Obtain a sterile sputum specimen.
- C. Have the client wait for 30 minutes.
- D. Place a warm washcloth on the client’s left hip.
Correct Answer: C
Rationale: Waiting 30 minutes post-antibiotic monitors for allergic reactions, critical for safety. Allergies should be checked pre-administration, sputum is diagnostic, and warm washcloths are not standard.
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.
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 ED nurse is caring for a client who had a severe allergic reaction to a bee sting. Which discharge instructions should the nurse discuss with the client?
- A. Instruct the client to wear a medical identification bracelet.
- B. Apply corticosteroid cream to the site to prevent anaphylaxis.
- C. Administer epinephrine 1:10,000 intravenously every three (3) minutes.
- D. Teach the client to avoid attracting insects by wearing bright colors.
Correct Answer: A
Rationale: A medical ID bracelet alerts others to the allergy, critical for future emergencies. Topical steroids don’t prevent anaphylaxis, IV epinephrine is hospital-based, and bright colors attract insects.
The male client was found in a parked car with the motor running. The paramedic brought the client to the ED with complaints of a headache, nausea, and dizziness and the client is unable to recall his name or address. On assessment, the nurse notes the buccal mucosa is a cherry-red color. Which intervention should the nurse implement first?
- A. Check the client’s oxygenation level with a pulse oximeter.
- B. Apply oxygen via nasal cannula at 100%.
- C. Obtain a psychiatric consult to determine if this was a suicide attempt.
- D. Prepare the client for transfer to a facility with a hyperbaric chamber.
Correct Answer: B
Rationale: Cherry-red mucosa suggests carbon monoxide (CO) poisoning; 100% oxygen via non-rebreather mask is the first intervention to displace CO. Pulse oximetry is unreliable, psychiatric consults are secondary, and hyperbaric transfer follows initial stabilization.