Nokea
The occupational health nurse is called to the scene of a traumatic amputation of a finger. Which intervention should the nurse implement prior to sending the client to the ED? Select all that apply.
- A. Rinse the amputated finger with sterile normal saline.
- B. Place the amputated finger in a sealed and watertight plastic bag.
- C. Place the amputated finger into iced saline solution.
- D. Wrap the amputated finger in saline-moistened gauze dressings.
- E. Replace the amputated finger on the hand and wrap with gauze.
Correct Answer: A,B,D
Rationale: Rinsing with saline, wrapping in moist gauze, and sealing in a plastic bag preserve the amputated finger for reimplantation. Iced saline damages tissue, and replacing on the hand is incorrect.
You may also like to solve these questions
The ED nurse is caring for a client who suffered a near-drowning. Which expected outcome should the nurse include in the plan of care for this client?
- A. Maintain the client’s cardiac function.
- B. Promote a continued decrease in lung surfactant.
- C. Warm rapidly to minimize the effects of hypothermia.
- D. Keep the oxygen saturation level above 93%.
Correct Answer: D
Rationale: Maintaining SpO2 >93% ensures adequate oxygenation post-near-drowning, preventing hypoxia. Cardiac function, surfactant loss, and rapid warming are secondary or incorrect.
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 Tourniquets, cutting, and steroids are outdated or secondary.
The ED nurse is caring for a client diagnosed with multiple rib fractures. Which data should the nurse include in the assessment?
- A. Level of orientation to time and place.
- B. Current use and last dose of medication.
- C. Symmetrical movement of the chest.
- D. Time of last meal the client ate.
Correct Answer: C
Rationale: Symmetrical chest movement assesses for complications like pneumothorax or flail chest in rib fractures. Orientation, medications, and meal timing are secondary.
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants intervention by the nurse?
- A. The UAP places a urine specimen in a biohazard bag in the hallway.
- B. The UAP uses the alcohol foam hand cleanser after removing gloves.
- C. The UAP puts soiled linen in a plastic bag in the client’s room.
- D. The UAP obtains a disposable stethoscope for a client in an isolation room.
Correct Answer: A
Rationale: Urine specimens are not biohazardous unless visibly bloody; placing in a biohazard bag is incorrect and requires intervention. Hand cleansing, linen handling, and stethoscope use are appropriate.
The nurse writes a nursing diagnosis of 'risk for injury as a result of physical abuse by spouse' for a client. Which is an appropriate goal for this client?
- A. The client will learn not to trust anyone.
- B. The client will admit the abuse is happening and get help.
- C. The client will discuss the nurse’s suspicions with the spouse.
- D. The client will choose to stay with the spouse.
Correct Answer: B
Rationale: Admitting abuse and seeking help is a realistic goal to reduce injury risk. Distrust, confronting the spouse, or staying are unsafe or neutral.