Emergency Nursing NCLEX
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Question 1 of 5.
The occupational health nurse is called to the scene of a traumatic amputation of a finger. Which intervention should the nurse implement prior to sending the client to the ED? Select all that apply.
A. Rinse the amputated finger with sterile normal saline.
B. Place the amputated finger in a sealed and watertight plastic bag.
C. Place the amputated finger into iced saline solution.
D. Wrap the amputated finger in saline-moistened gauze dressings.
E. Replace the amputated finger on the hand and wrap with gauze.
Explanation: Rinsing with saline, wrapping in moist gauze, and sealing in a plastic bag preserve the amputated finger for reimplantation. Iced saline damages tissue, and replacing on the hand is incorrect.
Question 2 of 5.
The client is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first?
A. Start an IV with an 18-gauge catheter.
B. Administer dopamine intravenous infusion.
C. Obtain arterial blood gases (ABGs).
D. Insert an indwelling urinary catheter.
Explanation: Hypovolemic shock (suggested by symptoms) requires immediate IV access for fluid resuscitation. Dopamine requires IV access, ABGs are diagnostic, and urinary catheter monitors output but is secondary.
Question 3 of 5.
The client is diagnosed with neurogenic shock. Which signs/symptoms should the nurse assess in this client?
A. Cool, moist skin.
B. Bradycardia.
C. Wheezing.
D. Decreased bowel sounds.
Explanation: Neurogenic shock causes bradycardia due to loss of sympathetic tone. Cool, moist skin is typical of hypovolemic shock, wheezing suggests anaphylaxis, and decreased bowel sounds are non-specific.
Question 4 of 5.
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants intervention by the nurse?
A. The UAP places a urine specimen in a biohazard bag in the hallway.
B. The UAP uses the alcohol foam hand cleanser after removing gloves.
C. The UAP puts soiled linen in a plastic bag in the client's room.
D. The UAP obtains a disposable stethoscope for a client in an isolation room.
Explanation: Urine specimens are not biohazardous unless visibly bloody; placing in a biohazard bag is incorrect and requires intervention. Hand cleansing, linen handling, and stethoscope use are appropriate.
Question 5 of 5.
The client diagnosed with septicemia is receiving a broad-spectrum antibiotic. Which laboratory data require the nurse to notify the health-care provider?
A. The client's potassium level is 3.8 mEq/L.
B. The urine culture indicates high sensitivity to the antibiotic.
C. The client's pulse oximeter reading is 94%.
D. The culture and sensitivity is resistant to the client's antibiotic.
Explanation: Antibiotic resistance requires immediate HCP notification to adjust therapy. Normal potassium, sensitive cultures, and 94% SpO2 are not urgent.
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