Nokea
Which intervention is most important for the nurse to implement when participating in a code?
- A. Elevate the arm after administering medication.
- B. Maintain sterile technique throughout the code.
- C. Treat the client’s signs/symptoms; do not treat the monitor.
- D. Provide accurate documentation of what happened during the code.
Correct Answer: C
Rationale: Treating the client’s clinical presentation (not just monitor readings) ensures appropriate care. Arm elevation, sterile technique, and documentation are secondary during active resuscitation.
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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.
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 charge nurse is making assignments. Which client should be assigned to the most experienced nurse?
- A. The client diagnosed with a snake bite who is receiving antivenin.
- B. The client who swallowed a lye preparation and is being discharged.
- C. The client who is angry the suicide attempt did not work.
- D. The client who required skin grafting after a chemical spill.
Correct Answer: A
Rationale: Antivenin administration for snake bites requires close monitoring for anaphylaxis and dosing, best handled by an experienced nurse. Lye ingestion discharge, psychiatric issues, and grafts are less acute.
The ED nurse is caring for a male client admitted with carbon monoxide poisoning. Which intervention requires the nurse to notify the rapid response team?
- A. The client has expectorated black sputum.
- B. The client reports trying to kill himself.
- C. The client’s pulse oximeter reading is 94%.
- D. The client has stridor and reports dizziness.
Correct Answer: D
Rationale: Stridor indicates airway obstruction, and dizziness suggests worsening CO toxicity, requiring rapid response. Black sputum, suicidal intent, and 94% SpO2 are less acute.
Which health-care team member referral should be made by the nurse when a code is being conducted on a client in a community hospital?
- A. The hospital chaplain.
- B. The social worker.
- C. The respiratory therapist.
- D. The director of nurses.
Correct Answer: C
Rationale: The respiratory therapist manages airway and ventilation during a code, critical for resuscitation. Chaplain, social worker, and director are supportive, not acute.