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Which situation warrants the nurse obtaining information from a material safety data sheet (MSDS)?
- A. The custodian spilled a chemical solvent in the hallway.
- B. A visitor slipped and fell on the floor that had just been mopped.
- C. A bottle of antineoplastic agent broke on the client’s floor.
- D. The nurse was stuck with a contaminated needle in the client’s room.
Correct Answer: A
Rationale: MSDS provides handling and exposure information for chemical spills like solvents. Antineoplastic spills require specific protocols, and needle sticks or falls involve infection control or safety protocols, not MSDS.
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The ED nurse is caring for a female client with a greenstick fracture of the left forearm and multiple contusions on the face, arms, trunk, and legs. The significant other is in the treatment area with the client. Which nursing interventions should the nurse implement? List in order of priority.
- A. Determine if the client has a plan for safety.
- B. Assess the pulse, temperature, and capillary refill of the left wrist and hand.
- C. Ask the client if she feels safe in her own home.
- D. Request the significant other wait in the waiting room during the examination.
- E. Notify the social worker to consult on the case.
Correct Answer: D,C,A,B,E
Rationale: 1) Request significant other to wait (ensures private assessment); 2) Ask about safety (screens for abuse); 3) Plan for safety (addresses immediate risk); 4) Assess limb (ensures circulation); 5) Notify social worker (coordinates support).
A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable about biochemical agents, is giving directions to the travelers. Which direction should the nurse provide to the travelers?
- A. Hold their breath as much as possible.
- B. Stand up to avoid heavy exposure.
- C. Lie down to stay under the exposure.
- D. Attempt to breathe through their clothing.
Correct Answer: C
Rationale: Lying down minimizes exposure to chemical agents, which may settle lower. Breath-holding is temporary, standing increases exposure, and clothing is minimally protective.
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.
The nurse is discharging a client from the ED with a sutured laceration on the right knee. Which information is most important for the nurse to obtain?
- A. The date of the client’s last tetanus injection.
- B. The name of the client’s regular health-care provider.
- C. Explain the sutures must be removed in 10 to 14 days.
- D. Determine if the client has any drug or food allergies.
Correct Answer: A
Rationale: Tetanus status is critical for lacerations to prevent infection, especially if >5 years since last dose. HCP name, suture removal, and allergies are secondary.
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.