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The nurse is teaching a class on bioterrorism. Which statement is the scientific rationale for designating a specific area for decontamination?
- A. Showers and privacy can be provided to the client in this area.
- B. This area isolates the clients who have been exposed to the agent.
- C. It provides a centralized area for stocking the needed supplies.
- D. It prevents secondary contamination to the health-care providers.
Correct Answer: D
Rationale: Decontamination areas prevent secondary contamination to HCPs, the primary rationale. Privacy, isolation, and supply stocking are secondary benefits.
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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.
The nurse is teaching CPR to a class. Which statement best explains the definition of sudden cardiac death?
- A. Cardiac death occurs after being removed from a mechanical ventilator.
- B. Cardiac death is the time the HCP officially declares the client dead.
- C. Cardiac death occurs within one (1) hour of the onset of cardiovascular symptoms.
- D. The death is caused by myocardial ischemia resulting from coronary artery disease.
Correct Answer: C
Rationale: Sudden cardiac death is defined as death within 1 hour of cardiovascular symptoms, often due to arrhythmias. Ventilator removal, declaration time, and ischemia are related but not definitional.
A gastric lavage has been ordered for a client who is comatose and who ingested a full bottle of acetaminophen, a nonnarcotic analgesic. Which intervention should be included in the procedure? Select all that apply.
- A. Place the client on the left side with the head 15 degrees lower than the body.
- B. Insert a small-bore feeding tube into the naris.
- C. Have standby suction available.
- D. Withdraw stomach contents and then instill an irrigating solution.
- E. Send samples of the stomach contents to the laboratory for analysis.
Correct Answer: A,C,D,E
Rationale: Left-side positioning with head down prevents aspiration, suction clears secretions, withdrawing and irrigating removes poison, and lab analysis confirms ingestion. Small-bore tubes are inadequate for lavage.
The triage nurse is working in the emergency department. Which client should be assessed first?
- A. The 10-year-old child whose dad thinks the child’s leg is broken.
- B. The 45-year-old male who is diaphoretic and clutching his chest.
- C. The 58-year-old female complaining of a headache and seeing spots.
- D. The 25-year-old male who cut his hand with a hunting knife.
Correct Answer: B
Rationale: Chest pain with diaphoresis suggests acute myocardial infarction, a life-threatening emergency requiring immediate assessment. Fractures, headaches, and cuts are less urgent.
The nurse is caring for clients on a medical floor. Which client is most likely to experience sudden cardiac death?
- A. The 84-year-old client exhibiting uncontrolled atrial fibrillation.
- B. The 60-year-old client exhibiting asymptomatic sinus bradycardia.
- C. The 53-year-old client exhibiting ventricular fibrillation.
- D. The 65-year-old client exhibiting supraventricular tachycardia.
Correct Answer: C
Rationale: Ventricular fibrillation is a lethal arrhythmia causing sudden cardiac death if untreated. Atrial fibrillation, bradycardia, and SVT are less immediately fatal.