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Which is the primary goal of the ED nurse in caring for a client who has ingested poison?
- A. Remove or inactivate the poison before it is absorbed.
- B. Provide long-term supportive care to prevent organ damage.
- C. Administer an antidote to increase the effects of the poison.
- D. Implement treatment prolonging the elimination of the poison.
Correct Answer: A
Rationale: Removing or inactivating the poison (e.g., via lavage or charcoal) prevents absorption, the primary goal. Supportive care, antidotes, and elimination are secondary.
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The male client presents to the emergency department stating he vomited a 'large' amount of bright red blood. Which should the nurse implement first?
- A. Start an intravenous line with an 18-gauge needle.
- B. Have the UAP take the client’s vital signs.
- C. Ask the client to provide a stool specimen for blood.
- D. Send the client to radiology for an abdominal CT scan.
Correct Answer: A
Rationale: Hematemesis suggests GI bleeding, requiring immediate IV access for fluids or blood. Vital signs, stool specimens, and CT scans follow stabilization.
The emergency department nurse writes the problem of 'ineffective coping' for a client who has been raped. Which intervention should the nurse implement?
- A. Encourage the client to take the 'morning-after' pill.
- B. Allow the client to admit guilt for causing the rape.
- C. Provide a list of rape crisis counselors.
- D. Discuss reporting the case to the police.
Correct Answer: C
Rationale: Rape crisis counselors provide specialized support for coping post-rape. Morning-after pill addresses pregnancy, guilt admission is harmful, and police reporting is client-driven.
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.
The nurse is providing discharge teaching for the client with intermaxillary wiring to repair a fractured mandible. Which statement by the client indicates teaching has been effective?
- A. Iced alcoholic drinks may be consumed by using a straw.
- B. Only one (1) food item should be consumed at one (1) time.
- C. Carbonated sodas should be limited to two (2) daily.
- D. Teeth can be brushed after tenderness and edema subside.
Correct Answer: D
Rationale: Brushing teeth after swelling subsides maintains oral hygiene safely. Alcohol, single food items, and soda limits are incorrect or unnecessary.
The client has been brought to the ED by ambulance following a motor-vehicle accident with a flail chest, an intravenous line, and a Heimlich valve. Which intervention should the nurse implement first?
- A. Start a large-bore intravenous access.
- B. Request a portable chest x-ray.
- C. Prepare to insert chest tubes.
- D. Assess the cardiac rhythm on the monitor.
Correct Answer: C
Rationale: A flail chest with a Heimlich valve indicates a pneumothorax; preparing for chest tube insertion stabilizes breathing, the priority. Additional IVs, x-rays, and cardiac monitoring follow.