Nokea
The nurse is providing first aid to a victim of a poisonous snake bite. Which intervention should be the nurse’s first action?
- A. Apply a tourniquet to the affected limb.
- B. Cut an 'X' across the bite and suck out the venom.
- C. Administer a corticosteroid medication.
- D. Have the client lie still and remove constrictive items.
Correct Answer: D
Rationale: Immobilizing the limb and removing constrictive items (e.g., jewelry) prevents venom spread and swelling, the first action. Tourniquets, cutting, and steroids are outdated or secondary.
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The charge nurse has been notified that a disaster has occurred and that all possible clients should be discharged so the floor can receive the casualties. Which client should not be discharged?
- A. The 13-year-old client who is scheduled for a tonsillectomy.
- B. The 42-year-old client scheduled for an abdominal aorta aneurysm dissection.
- C. The 76-year-old client diagnosed with a pulmonary embolus whose INR is 2.9.
- D. The 80-year-old client who is refusing to assist in activities of daily living.
Correct Answer: C
Rationale: A pulmonary embolus with INR 2.9 (therapeutic) requires ongoing anticoagulation and monitoring, precluding discharge. Tonsillectomy, aneurysm surgery, and ADL refusal are less acute.
The nurse in a disaster is triaging the following clients. Which client should be triaged as an Expectant Category, Priority 4, and color black?
- A. The client with a sucking chest wound who is alert.
- B. The client with a head injury who is unresponsive.
- C. The client with an abdominal wound and stable vital signs.
- D. The client with a sprained ankle which may be fractured.
Correct Answer: B
Rationale: Expectant (black) category includes unresponsive clients with minimal survival chance (e.g., severe head injury). Sucking chest wounds (red), abdominal wounds (yellow), and sprains (green) are higher priority.
The triage nurse in a large trauma center has been notified of an explosion in a major chemical manufacturing plant. Which action should the nurse implement first when the clients arrive at the emergency department?
- A. Triage the clients and send them to the appropriate areas.
- B. Thoroughly wash the clients with soap and water and then rinse.
- C. Remove the clients’ clothing and have them shower.
- D. Assume the clients have been decontaminated at the plant.
Correct Answer: C
Rationale: Removing contaminated clothing and showering prevents ongoing chemical exposure, the first priority. Triage follows, washing is part of decontamination, and assuming decontamination is unsafe.
Which question is an appropriate interview question for the nurse to use with clients involved in abuse?
- A. I know you are being abused. Can you tell me about it?
- B. How much does your spouse drink before he hits you?
- C. What did you do to cause your spouse to get mad?
- D. Do you have a plan if your partner becomes abusive?
Correct Answer: D
Rationale: Asking about a safety plan is non-judgmental and empowers the client. Accusatory, alcohol-focused, or blame-oriented questions hinder trust.
During a disaster, a local news reporter comes to the emergency department requesting information about the victims. Which action is most appropriate for the nurse to implement?
- A. Have security escort the reporter off the premises.
- B. Direct the reporter to the disaster command post.
- C. Tell the reporter this is a violation of HIPAA.
- D. Request the reporter to stay out of the way.
Correct Answer: B
Rationale: Directing the reporter to the command post ensures controlled information release, adhering to HIPAA. Escorting off, citing HIPAA, or requesting to stay out are less collaborative.