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The nurse is teaching a class on bioterrorism and is discussing personal protective equipment (PPE). Which statement is the most important fact for the nurse to share with the participants?
- A. Health-care facilities should keep masks at entry doors.
- B. The respondent should be trained in the proper use of PPE.
- C. No single combination of PPE protects against all hazards.
- D. The EPA has divided PPE into four levels of protection.
Correct Answer: B
Rationale: Proper PPE training ensures safe use, critical for protection. Mask placement, hazard specificity, and EPA levels are secondary.
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The female client presents to the emergency department with facial lacerations and contusions. The spouse will not leave the room during the assessment interview. Which intervention should be the nurse’s first action?
- A. Call the security guard to escort the spouse away.
- B. Discuss the injuries while the spouse is in the room.
- C. Tell the spouse the police will want to talk to him.
- D. Escort the client to the bathroom for a urine specimen.
Correct Answer: D
Rationale: Escorting the client to the bathroom provides a private opportunity to assess for abuse safely. Security, discussing injuries, or mentioning police may escalate the situation.
The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse?
- A. Vital signs T 100.4°F, P 104, R 26, and BP 102/60.
- B. A white blood cell count of 18,000/mm3.
- C. A urinary output of 90 mL in the last four (4) hours.
- D. The client complains of being thirsty.
Correct Answer: C
Rationale: Urinary output of 90 mL/4 hours = 22.5 mL/hour, below 30 mL/hour, indicating renal hypoperfusion, requiring immediate intervention. Fever, tachycardia, and elevated WBC are expected; thirst is less urgent.
The adolescent female comes to the school nurse of an intermediate school and tells the nurse she thinks she is pregnant. During the interview, the client states her father is the baby’s father. Which intervention should the nurse implement first?
- A. Complete a rape kit.
- B. Notify Child Protective Services.
- C. Call the parents to come to the school.
- D. Arrange for the client to go to a free clinic.
Correct Answer: B
Rationale: Alleged paternal incest requires immediate Child Protective Services notification as a mandatory reporter. Rape kit, parental contact, or clinic referral follow after ensuring safety.
The parents bring their toddler to the ED in a panic. The parents state the child had been playing in the kitchen and got into some cleaning agents and swallowed an unknown quantity of the agents. Which health-care agency should the nurse contact at this time?
- A. Child Protective Services (CPS).
- B. The local police department.
- C. The Department of Health.
- D. The Poison Control Center.
Correct Answer: D
Rationale: The Poison Control Center provides immediate guidance on ingested toxins, critical for treatment. CPS, police, and health departments are secondary.
The nurse is teaching a class on biological warfare. Which information should the nurse include in the presentation?
- A. Contaminated water is the only source of transmission of biological agents.
- B. Vaccines are available and being prepared to counteract biological agents.
- C. Biological weapons are less of a threat than chemical agents.
- D. Biological weapons are easily obtained and result in significant mortality.
Correct Answer: D
Rationale: Biological weapons are easily obtained (e.g., anthrax) and cause high mortality, making them a significant threat. Water is not the only transmission route, vaccines are limited, and biological threats rival chemical ones.