Which type of agent does sulfur mustard fall under?
- A. Nerve agents
- B. Blistering agents
- C. Respiratory toxins
- D. Cyanide poisonings
Correct Answer: B
Rationale: The correct answer is B because sulfur mustard is a blistering agent that causes skin and respiratory damage.
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When assessing a client with a pneumothorax and a chest tube, which finding should the nurse notify the provider about?
- A. Movement of the trachea toward the unaffected side
- B. Bubbling of the water in the water seal chamber with exhalation
- C. Crepitus in the area above and surrounding the insertion site
- D. Eyelets not visible
Correct Answer: A
Rationale: Step 1: Movement of the trachea toward the unaffected side indicates tension pneumothorax, a life-threatening condition requiring immediate intervention.
Step 2: This finding can lead to compromised breathing and hemodynamic instability if not addressed promptly.
Step 3: B: Bubbling in the water seal chamber with exhalation is expected in a properly functioning chest tube system.
Step 4: C: Crepitus at the insertion site is common due to air entering subcutaneous tissue during tube placement and is not an urgent concern.
Step 5: D: Eyelets not visible can indicate dislodgement but is not as critical as tracheal deviation in this scenario.
When caring for a client with pain, which of the following is essential throughout the client’s care?
- A. Giving assurance that pain management is a nursing and agency priority.
- B. Giving assurance that pain relief will be immediate and effective.
- C. Giving assurance that pain relief will be permanent.
- D. Giving assurance that pain has a psychological basis and can be easily managed.
Correct Answer: A
Rationale: The correct answer is A because ensuring that pain management is prioritized by both nursing staff and the healthcare facility is crucial for consistent and effective care.
Patient teaching for risk reduction of skin cancer should include
- A. Having suspicious moles checked by a dermatologist.
- B. Daily sun exposure every 1/2 hour.
- C. Daily sun exposure of 1 hour to build tolerance.
- D. Applying moisturizer.
Correct Answer: A
Rationale: Regular monitoring of moles and avoiding excessive sun exposure are vital for skin cancer prevention.
A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
- A. Raise the foot of the bed to a 90° angle
- B. Remove the dressing to inspect the wound
- C. Prepare to insert a central line
- D. Administer oxygen via nasal cannula
Correct Answer: D
Rationale: The correct answer is D: Administer oxygen via nasal cannula. In a client with a sucking chest wound, the priority is to ensure adequate oxygenation due to potential respiratory compromise. Administering oxygen via nasal cannula will help improve oxygenation and support the client's respiratory function. This action takes precedence over other interventions as hypoxia can lead to further deterioration.
A: Raising the foot of the bed to a 90° angle is not indicated in this situation as it does not address the immediate need for oxygenation.
B: Removing the dressing to inspect the wound can worsen the condition by disrupting any seals in place to prevent air from entering the chest cavity.
C: Preparing to insert a central line is not the priority in this situation as the client's respiratory status needs to be stabilized first.
How can a nurse foster effective coping skills?
- A. Deep breathing exercises
- B. Avoid social interactions
- C. Ignore stressors
- D. Increase workload
Correct Answer: B
Rationale: The correct answer is B because it is the most appropriate response based on physiological and medical principles.
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