Nokea
The nurse working in the emergency department is admitting a 34-year-old female client for one of multiple admissions for spousal abuse. The client has refused to leave her husband or to press charges against him. Which action should the nurse implement?
- A. Insist the woman press charges this time.
- B. Treat the wounds and do nothing else.
- C. Tell the woman her husband could kill her.
- D. Give the woman the number of a women’s shelter.
Correct Answer: D
Rationale: Providing a women’s shelter number empowers the client with resources without coercion. Insisting on charges, minimal treatment, or fear tactics disrespect autonomy.
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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.
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.
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.
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.