Nokea
Which cultural issues should the nurse consider when caring for clients during a bioterrorism attack? Select all that apply.
- A. Language difficulties.
- B. Religious practices.
- C. Prayer times for the people.
- D. Rituals for handling the dead.
- E. Keeping the family in the designated area.
Correct Answer: A,B,C,D
Rationale: Language, religious practices, prayer times, and death rituals affect care delivery in bioterrorism scenarios. Family containment is logistical, not cultural.
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A gang war has resulted in 12 young males being brought to the emergency department. Which action by the nurse is priority when a gang member points a gun at a rival gang member in the trauma room?
- A. Attempt to talk to the person who has the gun.
- B. Explain to the person the police are coming.
- C. Stand between the client and the man with the gun.
- D. Get out of the line of fire and protect self.
Correct Answer: D
Rationale: Self-protection by exiting the line of fire prioritizes nurse safety, allowing for security intervention. Talking, explaining police arrival, or standing between risks harm.
Which question is an appropriate interview question for the nurse to use with clients involved in abuse?
- A. I know you are being abused. Can you tell me about it?
- B. How much does your spouse drink before he hits you?
- C. What did you do to cause your spouse to get mad?
- D. Do you have a plan if your partner becomes abusive?
Correct Answer: D
Rationale: Asking about a safety plan is non-judgmental and empowers the client. Accusatory, alcohol-focused, or blame-oriented questions hinder trust.
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 triage nurse in a large trauma center has been notified of an explosion in a major chemical manufacturing plant. Which action should the nurse implement first when the clients arrive at the emergency department?
- A. Triage the clients and send them to the appropriate areas.
- B. Thoroughly wash the clients with soap and water and then rinse.
- C. Remove the clients’ clothing and have them shower.
- D. Assume the clients have been decontaminated at the plant.
Correct Answer: C
Rationale: Removing contaminated clothing and showering prevents ongoing chemical exposure, the first priority. Triage follows, washing is part of decontamination, and assuming decontamination is unsafe.
The ED nurse is completing the initial assessment on a client who becomes unresponsive. Which intervention should the nurse implement first?
- A. Assess the rate and site of the intravenous fluid.
- B. Administer an ampule of sodium bicarbonate.
- C. Assess the cardiac rhythm shown on the monitor.
- D. Prepare to cardiovert the client into sinus rhythm.
Correct Answer: C
Rationale: Assessing the cardiac rhythm determines the cause of unresponsiveness (e.g., arrhythmia), guiding ACLS interventions. IV checks, bicarbonate, and cardioversion follow.