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The nurse is working at a facility where an Ebola client has been admitted. Which action should the nurse take?
- A. Consult the nurse manager regarding the infection-control standards to follow.
- B. Resign immediately and leave the facility.
- C. Watch the television news reports to identify which station has the client.
- D. Participate in a news report about the quality of care provided at the hospital.
Correct Answer: A
Rationale: Consulting the nurse manager ensures adherence to Ebola-specific infection control (e.g., PPE, isolation). Resigning, watching news, or participating in reports are inappropriate.
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Which situation warrants the nurse obtaining information from a material safety data sheet (MSDS)?
- A. The custodian spilled a chemical solvent in the hallway.
- B. A visitor slipped and fell on the floor that had just been mopped.
- C. A bottle of antineoplastic agent broke on the client’s floor.
- D. The nurse was stuck with a contaminated needle in the client’s room.
Correct Answer: A
Rationale: MSDS provides handling and exposure information for chemical spills like solvents. Antineoplastic spills require specific protocols, and needle sticks or falls involve infection control or safety protocols, not MSDS.
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.
A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable about biochemical agents, is giving directions to the travelers. Which direction should the nurse provide to the travelers?
- A. Hold their breath as much as possible.
- B. Stand up to avoid heavy exposure.
- C. Lie down to stay under the exposure.
- D. Attempt to breathe through their clothing.
Correct Answer: C
Rationale: Lying down minimizes exposure to chemical agents, which may settle lower. Breath-holding is temporary, standing increases exposure, and clothing is minimally protective.
The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect?
- A. Cardiogenic shock.
- B. Hypovolemic shock.
- C. Neurogenic shock.
- D. Septic shock.
Correct Answer: B
Rationale: NSAID-induced gastrointestinal bleeding can cause hypovolemic shock, indicated by tachycardia, hypotension, and pale, clammy skin. Cardiogenic involves cardiac failure, neurogenic involves bradycardia, and septic involves fever.
The ED nurse is working triage. Which client should be triaged first?
- A. A client who has multiple injuries from a motor-vehicle accident.
- B. A client complaining of epigastric pain and nausea after eating.
- C. An elderly client who fell and fractured the left femoral neck.
- D. The client suffering from a migraine headache and nausea.
Correct Answer: A
Rationale: Multiple trauma from an MVA suggests life-threatening injuries, requiring immediate triage. Epigastric pain, fractures, and migraines are less urgent.