A young man playing football in the park sustains a hard hit and is lying motionless on the ground, while his friends are trying to help him. Which action by his friends warrants immediate intervention by the nurse who was watching from the sidelines?
The football player's girlfriend is crying and screaming for help.
A fellow football player is encouraging the victim to try and sit up.
Several friends are walking around the accident victim and staring at him.
One of the friends is calling a relative to tell them about the accident.
The Correct Answer is B
Rationale:
A. The football player’s girlfriend is crying and screaming for help: Emotional distress from bystanders is common in emergencies but does not directly endanger the injured person. While the nurse may need to calm her later, it is not the most urgent issue.
B. A fellow football player is encouraging the victim to try and sit up: Encouraging movement in a client with a potential neck or spinal injury can cause further spinal cord damage or paralysis. The nurse must immediately stop this action, maintain cervical spine immobilization, and ensure that emergency services are called.
C. Several friends are walking around the accident victim and staring at him: Although this may interfere with rescue efforts or crowd control, it poses no immediate physical threat to the injured client. It can be managed after ensuring spinal precautions are in place.
D. One of the friends is calling a relative to tell them about the accident: Contacting the family is appropriate once emergency services have been alerted and care is being provided. This action does not interfere with the client’s immediate safety or neurological stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.3"]
Explanation
Calculation
Ordered Dose (D): 3 mg
Available Concentration (H): 30 mg / 3 mL
= 10 mg/mL
- Calculate the Volume (mL) to Administer
Amount to Administer (mL) = (Ordered Dose (D) / Dose on Hand (H)) x Quantity (Q)
= (3 mg / 10 mg) x 1 mL
= 0.3 x 1 mL
= 0.3 mL
Correct Answer is B
Explanation
Rationale
A. Ventricular tachycardia (VT): VT is characterized by a rapid heart rate, usually 100 to 250 beats/minute, with wide and bizarre QRS complexes that are regular in rhythm. The rhythm strip provided is completely chaotic and irregular, without identifiable QRS complexes or a discernible rate, therefore it is not ventricular tachycardia.
B. Ventricular fibrillation (VF): This rhythm is characterized by chaotic, erratic electrical activity in the ventricles, resulting in a quivering but non-pumping heart. The ECG strip shows total disorganization of ventricular electrical activity, with no recognizable P waves, QRS complexes, or T waves, appearing as a chaotic, wavy baseline.
C. Atrial fibrillation (A-fib): A-fib is characterized by an irregularly irregular rhythm with no discernible P waves. However, the QRS complexes are typically narrow and still present. The rhythm strip shown lacks any recognizable QRS complexes and is too chaotic to be A-fib.
D. Third degree heart block (Complete Heart Block): Third-degree heart block is characterized by complete dissociation between the atria and ventricles, meaning the P waves and QRS complexes march out independently. While the rate is usually slow, both P waves and QRS complexes are still visible on the strip
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