Nokea
While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. Which action should the nurse take first?
- A. Deliver rescue breaths.
- B. Wrap the client in dry blankets.
- C. Assess for signs of bleeding.
- D. Check for a cerebral pulse.
Correct Answer: A
Rationale: Agonal breathing indicates inadequate ventilation. Delivering rescue breaths is the priority to restore airway and ventilation. Wrapping in blankets or assessing bleeding are secondary, and cerebral pulse is not a standard assessment.
You may also like to solve these questions
A nurse teaches a client who has severe allergies to prevent bug bites. Which statements should the nurse include in this client's teaching? (Select all that apply.)
- A. Consult an exterminator to control bugs in and around your home.
- B. Wear synthetic clothing that dries quickly.
- C. Use insect repellent with DEET.
- D. Wear long sleeves and pants in wooded areas.
- E. Avoid wearing bright colors or strong perfumes.
Correct Answer: A,C,D,E
Rationale: Consulting an exterminator, using DEET repellent, wearing protective clothing, and avoiding attractants like bright colors or perfumes reduce bug bite risk. Synthetic clothing drying quickly is not directly relevant to preventing bites.
A nurse assesses a client recently bitten by a coral snake. Which assessment should the nurse complete first?
- A. Unilateral peripheral swelling
- B. Clotting times
- C. Cardiac rhythm
- D. Electrocardiogram rhythm
Correct Answer: C
Rationale: Coral snake venom is neurotoxic, causing ascending paralysis and respiratory compromise. Assessing cardiac rhythm is critical to detect early signs of systemic effects. Swelling and clotting issues are more associated with pit viper bites, and ECG rhythm is redundant with cardiac rhythm.
After teaching a client how to prevent altitude-related illnesses, a nurse assesses the client's understanding. Which statement indicates the client needs additional teaching?
- A. If my climbing partner can't think straight, we should descend to a lower altitude.
- B. I will ask my provider about medications to help prevent acute mountain sickness.
- C. My partner and I will plan to sleep at a higher elevation to acclimate more quickly.
- D. I will drink plenty of fluids to stay hydrated while on the mountain.
Correct Answer: C
Rationale: Sleeping at a higher elevation can worsen altitude sickness. The client should be taught to sleep at a lower elevation to acclimate safely. The other statements reflect appropriate understanding of altitude illness prevention.
An emergency department nurse cares for a middle-aged mountain climber who is confused and exhibits bizarre behaviors. After administering oxygen, which priority intervention should the nurse implement?
- A. Administer dexamethasone (Decadron).
- B. Complete a mental status examination.
- C. Request the client for computed tomography of the brain.
- D. Request a psychiatric consult.
Correct Answer: A
Rationale: The client is exhibiting signs of mountain sickness and high altitude cerebral edema (HACE). Dexamethasone reduces cerebral edema by acting as an anti-inflammatory in the central nervous system. The other interventions will not treat mountain sickness or HACE.
A provider prescribes Crotalidae Polyvalent Immune Fab (CroFab) for a client who is admitted after being bitten by a pit viper snake. Which assessment should the nurse complete prior to administering this medication?
- A. Inspect the temperature for signs of fever.
- B. Check the client's creatine kinase level.
- C. Ask about allergies to pineapple or papaya.
- D. Inspect the skin for signs of internal hives.
Correct Answer: C
Rationale: CroFab is an antivenom for pit viper bites. Assessing for allergies to pineapple or papaya (due to bromelain and papain components) is critical to prevent hypersensitivity reactions. Other assessments are relevant but not the priority before administration.