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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.
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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.
The ED nurse is caring for the client who has taken an overdose of cocaine. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Evaluate the airway and breathing.
- B. Monitor the rate of intravenous fluids.
- C. Place the cardiac monitor on the client.
- D. Transfer the client to the intensive care unit.
Correct Answer: C
Rationale: Placing a cardiac monitor is a technical task delegable to UAPs. Airway evaluation, IV monitoring, and transfers require nursing judgment.
According to the North Atlantic Treaty Organization (NATO) triage system, which situation is considered a level red (Priority 1)?
- A. Injuries are extensive and chances of survival are unlikely.
- B. Injuries are minor and treatment can be delayed hours to days.
- C. Injuries are significant but can wait hours without threat to life or limb.
- D. Injuries are life threatening but survivable with minimal interventions.
Correct Answer: D
Rationale: NATO red (Priority 1) indicates life-threatening injuries survivable with immediate intervention (e.g., tension pneumothorax). Extensive injuries are black, minor are green, and significant but delayed are yellow.
The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse?
- A. Vital signs T 100.4°F, P 104, R 26, and BP 102/60.
- B. A white blood cell count of 18,000/mm3.
- C. A urinary output of 90 mL in the last four (4) hours.
- D. The client complains of being thirsty.
Correct Answer: C
Rationale: Urinary output of 90 mL/4 hours = 22.5 mL/hour, below 30 mL/hour, indicating renal hypoperfusion, requiring immediate intervention. Fever, tachycardia, and elevated WBC are expected; thirst is less urgent.