Nokea
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.
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The unlicensed assistive personnel (UAP) is performing cardiac compressions on an adult client during a code. Which behavior warrants immediate intervention by the nurse?
- A. The UAP has hand placement on the lower half of the sternum.
- B. The UAP performs cardiac compressions and allows for rescue breathing.
- C. The UAP depresses the sternum 0.5 to one (1) inch during compressions.
- D. The UAP asks to be relieved from performing compressions because of exhaustion.
Correct Answer: C
Rationale: Compressions should depress the sternum 2–2.4 inches; 0.5–1 inch is inadequate, requiring intervention. Correct hand placement, rescue breathing, and relief requests are appropriate.
The 84-year-old female client is admitted with multiple burn marks on the torso and under the breasts along with contusions in various stages of healing. When questioned by the nurse, the woman denies any problems have occurred. The woman lives with her son and does the housework. Which is the most probable reason the woman denies being abused?
- A. There has not been any abuse to report.
- B. The client is ashamed to admit being abused.
- C. The client has Alzheimer’s disease and can’t remember.
- D. The client has engaged in consensual sex.
Correct Answer: B
Rationale: Shame often leads elderly abuse victims to deny abuse, especially when dependent on the abuser (e.g., son). Lack of abuse is unlikely given findings, Alzheimer’s is speculative, and sex is unrelated.
The ED nurse is caring for a client with fractured pelvis and bladder trauma secondary to a motor-vehicle accident. Which data are most important for the nurse to assess?
- A. Monitor the creatinine and BUN.
- B. Check urine output hourly.
- C. Note the amount and color of the urine.
- D. Assess for bladder distention.
Correct Answer: C
Rationale: Amount and color of urine (e.g., hematuria) indicate bladder trauma severity, guiding intervention. Creatinine/BUN, output, and distention are important but secondary.
A nurse is at the lake when a person nearly drowns. The nurse determines the client is breathing spontaneously. Which data should the nurse assess next?
- A. Possibility of drug use.
- B. Spinal cord injury.
- C. Level of confusion.
- D. Amount of alcohol.
Correct Answer: B
Rationale: Spinal cord injury assessment is critical post-near-drowning due to potential diving-related trauma, affecting stabilization. Confusion, drug use, and alcohol are secondary.
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.