In the work setting, what is the primary responsibility of the nurse in preparation for disaster management, that includes natural disasters and bioterrorism incidents?
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Solution
Being aware of the agency’s emergency response plan.
In disasters preparedness, the nurse should know the emergency response plan. This gives guidance that includes the roles of the team members, responsibilities and mechanism of reporting.
A nurse is providing discharge instruction to a woman who has been treated for contusions and bruises due to a domestic violence. What is the priority intervention for this client?
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Solution
Arranging transportation to a safe house.
Safety is a priority for this client and she should not return to a place where violence could recur.
Options A, B, and C: These are important for the long-term management of this case.
An intoxicated client comes into the emergency unit with an uncooperative behavior, mild confusion, and with slurred speech. The client is unable to provide a good history but he verbalizes that he has been drinking a lot. Which of the following is a priority action of the nurse?
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Solution
Administer IV fluid incorporated with Vitamin B1 as ordered.
The client has symptoms of alcohol abuse and there is a risk for Wernicke syndrome, which is caused by a deficiency in Vitamin B.
Option B: Multiple drug abuse is not uncommon; however, there is currently nothing to suggest an opiate overdose that requires the administration of naloxone.
Options C and D: Additional information or the results of the blood alcohol testing are part of the management but should not delay the immediate treatment.
An anxious female client complains of chest tightness, tingling sensations, and palpitations. Deep, rapid breathing, and carpal spasms are noted. Which of the following priority action should the nurse do first?
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Solution
Have the client breathe into a brown paper bag.
The client is suffering from hyperventilation secondary from anxiety, the initial action is to let the client breathe in a paper bag that will allow the rebreathing of carbon dioxide.
The following clients are presented with signs and symptoms of heat-related illness. Which of them needs to be attended first?
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Solution
A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown.
The signs and symptoms manifested by the homeless person indicate that a heat stroke is happening, a medical emergency, which can lead to brain damage.
Option A: The homemaker is experiencing heat exhaustion, which can be managed by fluids and cooling measures.
Option B: The elderly client is at risk for heat syncope and should be advised to rest in a cool area and avoid similar situations.
Option D: The runner is experiencing heat cramps, which can be managed with fluid and rest.
The following clients come at the emergency department complaining of acute abdominal pain. Prioritize them for care in order of the severity of the conditions.
1. A 27-year-old woman complaining of lightheadedness and severe sharp left lower quadrant pain who reports she is possibly pregnant.
2. A 43-year-old woman with moderate right upper quadrant pain who has vomited small amounts of yellow bile and whose symptoms have worsened over the week.
3. A 15-year-old boy with a low-grade fever, right lower quadrant pain, vomiting, nausea, and loss of appetite for the past few days.
4. A 57-year-old woman who complains of a sore throat and gnawing midepigastric pain that is worse between meals and during the night.
5. A 59-year-old man with a pulsating abdominal mass and sudden onset of persistent abdominal or back pain, which can be described as a tearing sensation within the past hour.
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Solution
5,1,3,2,4
The client with a pulsating mass has an abdominal aneurysm that may rupture and he may decompensate easily. The woman with lower left quadrant pain is at risk for a life-threatening ectopic pregnancy. The 15-year-old boy needs evaluation to rule out appendicitis. The woman with vomiting needs evaluation for gallbladder problems, which appear to be worsening. Lastly, the woman with mid epigastric pain is suffering from an ulcer, but follow-up diagnostic testing can be scheduled with a primary care provider.
A 5-year-old client was admitted to the emergency unit due to ingestion of unknown amount of chewable vitamins for children at an unknown time. Upon assessment, the child is alert and with no symptoms. Which of the following information should be reported to the physician immediately?
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Solution
The vitamin that was ingested contains iron.
Iron is a toxic substance that can lead to massive hemorrhage, shock, coma, and kidney failure.
Options A, C, and D: These information needs further investigation but will not change the immediate diagnostic testing or treatment plan.
A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours, should be reported to the physician immediately?
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Solution
Drainage of a clear fluid from the client’s nose.
Clear drainage from the client’s nose indicates that there is a leakage of CSF and should be reported to the physician immediately.
A client arrives in the emergency unit and reports that a concentrated household cleaner was splashed in both eyes. Which of the following nursing actions is a priority?
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Solution
Flush the eye repeatedly using sterile normal saline.
Initial emergency action during a chemical splash to the eye includes immediate continuous irrigation of the affected eye with normal saline.
Option A: Restasis (Allergan) drops are used to treat dry eyes.
Option C: Patching the eye is not part of the first line treatment of a chemical splash.
Option D: After irrigation, visual acuity then is assessed.
A client suffered an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to an LPN/LVN?
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Solution
Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in an ice.