Nokea
The nurse is providing discharge teaching for the client with intermaxillary wiring to repair a fractured mandible. Which statement by the client indicates teaching has been effective?
- A. Iced alcoholic drinks may be consumed by using a straw.
- B. Only one (1) food item should be consumed at one (1) time.
- C. Carbonated sodas should be limited to two (2) daily.
- D. Teeth can be brushed after tenderness and edema subside.
Correct Answer: D
Rationale: Brushing teeth after swelling subsides maintains oral hygiene safely. Alcohol, single food items, and soda limits are incorrect or unnecessary.
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Which is the primary goal of the ED nurse in caring for a client who has ingested poison?
- A. Remove or inactivate the poison before it is absorbed.
- B. Provide long-term supportive care to prevent organ damage.
- C. Administer an antidote to increase the effects of the poison.
- D. Implement treatment prolonging the elimination of the poison.
Correct Answer: A
Rationale: Removing or inactivating the poison (e.g., via lavage or charcoal) prevents absorption, the primary goal. Supportive care, antidotes, and elimination are secondary.
A nurse is at the lake when a person nearly drowns. The nurse determines the client is breathing spontaneously. Which data should the nurse assess next?
- A. Possibility of drug use.
- B. Spinal cord injury.
- C. Level of confusion.
- D. Amount of alcohol.
Correct Answer: B
Rationale: Spinal cord injury assessment is critical post-near-drowning due to potential diving-related trauma, affecting stabilization. Confusion, drug use, and alcohol are secondary.
The ED nurse is caring for a client diagnosed with frostbite of the feet. Which intervention should the nurse implement?
- A. Massage the feet vigorously.
- B. Soak the feet in warm water.
- C. Apply a heating pad to feet.
- D. Apply petroleum jelly to feet.
Correct Answer: B
Rationale: Soaking in warm water (40–42°C) gradually rewarms frostbitten tissue, preventing damage. Massage risks tissue injury, heating pads cause burns, and petroleum jelly is ineffective.
The elderly client is brought to the ED complaining of cramps, headache, and weakness after working outside in the sun. The telemetry shows sinus tachycardia. Which intervention should the nurse implement?
- A. Determine if the client is experiencing any thirst.
- B. Administer D5W intravenously at 250 mL/hr.
- C. Maintain a cool environment to promote rest.
- D. Withhold the client’s oral intake.
Correct Answer: C
Rationale: Heat exhaustion (suggested by symptoms) requires a cool environment to reduce core temperature. Thirst assessment, D5W, and withholding intake are secondary or incorrect.
The male client presents to the emergency department stating he vomited a 'large' amount of bright red blood. Which should the nurse implement first?
- A. Start an intravenous line with an 18-gauge needle.
- B. Have the UAP take the client’s vital signs.
- C. Ask the client to provide a stool specimen for blood.
- D. Send the client to radiology for an abdominal CT scan.
Correct Answer: A
Rationale: Hematemesis suggests GI bleeding, requiring immediate IV access for fluids or blood. Vital signs, stool specimens, and CT scans follow stabilization.