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Which federal agency is a resource for the nurse volunteering at the American Red Cross who is on a committee to prepare the community for any type of disaster?
- A. The Joint Commission (JC).
- B. Office of Emergency Management (OEM).
- C. Department of Health and Human Services (DHHS).
- D. Metro Medical Response Systems (MMRS).
Correct Answer: B
Rationale: The OEM coordinates disaster preparedness and response, a key resource for Red Cross volunteers. JC accredits facilities, DHHS oversees health, and MMRS is local.
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Which intervention is the most important for the intensive care unit nurse to implement when performing mouth-to-mouth resuscitation on a client who has pulseless ventricular fibrillation?
- A. Perform the jaw thrust maneuver to open the airway.
- B. Use the mouth to cover the client’s mouth and nose.
- C. Insert an oral airway prior to performing mouth to mouth.
- D. Use a pocket mouth shield to cover the client’s mouth.
Correct Answer: A
Rationale: The jaw thrust opens the airway without neck manipulation, critical in suspected trauma or codes. Covering mouth and nose, oral airways, and shields are secondary or less safe.
The client who was abused as a child is diagnosed with post-traumatic stress disorder (PTSD). Which intervention should the nurse implement when the client is resting?
- A. Call the client’s name to awaken him or her, but don’t touch the client.
- B. Touch the client gently to let him or her know you are in the room.
- C. Enter the room as quietly as possible to not disturb the client.
- D. Do not allow the client to be awakened at all when sleeping.
Correct Answer: A
Rationale: Calling the name without touching avoids startling a PTSD client, preventing flashbacks. Touching, quiet entry, or preventing awakening may trigger or disrupt.
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 in the emergency department administered an intramuscular antibiotic in the left gluteal muscle to the client with pneumonia who is being discharged home. Which intervention should the nurse implement?
- A. Ask the client about drug allergies.
- B. Obtain a sterile sputum specimen.
- C. Have the client wait for 30 minutes.
- D. Place a warm washcloth on the client’s left hip.
Correct Answer: C
Rationale: Waiting 30 minutes post-antibiotic monitors for allergic reactions, critical for safety. Allergies should be checked pre-administration, sputum is diagnostic, and warm washcloths are not standard.
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.