Nokea
The nurse is teaching a class about rape prevention to a group of women at a community center. Which information is not a myth about rape?
- A. Women who are raped asked for it by dressing provocatively.
- B. If a woman says no, it is a come on and she really does not mean it.
- C. Rape is an attempt to exert power and control over the client.
- D. All victims of sexual assault are women; men can’t be raped.
Correct Answer: C
Rationale: Rape is about power and control, not sexual desire, a fact. Provocative dressing, misinterpreting 'no,' and excluding male victims are myths.
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The ED nurse is caring for a male client admitted with carbon monoxide poisoning. Which intervention requires the nurse to notify the rapid response team?
- A. The client has expectorated black sputum.
- B. The client reports trying to kill himself.
- C. The client’s pulse oximeter reading is 94%.
- D. The client has stridor and reports dizziness.
Correct Answer: D
Rationale: Stridor indicates airway obstruction, and dizziness suggests worsening CO toxicity, requiring rapid response. Black sputum, suicidal intent, and 94% SpO2 are less acute.
The charge nurse is making assignments. Which client should be assigned to the most experienced nurse?
- A. The client diagnosed with a snake bite who is receiving antivenin.
- B. The client who swallowed a lye preparation and is being discharged.
- C. The client who is angry the suicide attempt did not work.
- D. The client who required skin grafting after a chemical spill.
Correct Answer: A
Rationale: Antivenin administration for snake bites requires close monitoring for anaphylaxis and dosing, best handled by an experienced nurse. Lye ingestion discharge, psychiatric issues, and grafts are less acute.
A student reports to the school nurse with complaints of stinging and burning from a wasp sting. Which intervention should the nurse implement?
- A. Grasp the stinger and pull it out.
- B. Apply a warm, moist soak to the area.
- C. Cleanse the site with alcohol.
- D. Apply an ice pack to the site.
Correct Answer: D
Rationale: An ice pack reduces pain and swelling from a wasp sting. Removing the stinger is unnecessary (wasps don’t leave stingers), warm soaks increase swelling, and alcohol is ineffective.
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.
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.