Test 1- Chapter 9

The elementary school nurse is teaching children how to prevent injuries from cold exposure in the winter. Which student statement demonstrates that the teaching has been effective? "Dressing in layers is important." "I will drink lots of water when I exercise." "Taking frequent breaks will help me rest." "Wearing three pairs of cotton socks is very important."

"Dressing in layers is important." Teaching has been effective when the student states that "Dressing in layers is important." Layering is very helpful in preventing cold injuries. The inner layer of clothing will provide insulation and the outer layers will help protect from wind and moisture. Lightweight and synthetic fabrics are preferable.Drinking lots of water and taking frequent breaks are more often associated with heat-related injuries. Although wearing layers is important, cotton socks are not the best choice as they will prevent evaporation of any moisture and can lead to hypothermia. Wearing three pairs of socks can decrease circulation to the toes increasing the risk of frostbite.

The nurse is teaching a class of park ranger trainees about prioritizing care for clients who have received snakebites. Which ranger's statement demonstrates a need for further teaching? "Do not allow the victim to ingest any alcohol or caffeine." "The extremity should be kept below the level of the heart." "The first priority is to call for EMS transport to a trauma center." "You should first place a tourniquet above the bite."

"You should first place a tourniquet above the bite." The ranger trainee's statement that the first thing to do is to place a tourniquet above the bite indicates a need for further teaching. Placing a tourniquet above the bite could worsen local tissue necrosis by retaining venom in the tissues. If transportation and treatment are delayed, a constricting band may be applied proximal to an extremity wound to slow venom circulation via lymphatic flow. However, it would not be used as a tourniquet.Alcohol or stimulants such as caffeinated beverages must not be offered because they may speed up the absorption of venom. Affected extremities are kept below the level of the heart. The first priority is not to call for EMS transport although it will be important for the client to be evaluated and treated at an appropriate facility that is equipped to handle snakebites.

Which client is at greatest risk for heat exhaustion? A 24-year-old construction worker A 34-year-old police officer A 42-year-old swimming instructor A 78-year-old gardener

A 78-year-old gardener Older adults are particularly at risk for heat-related illnesses because of decreased body fluid volume. Heat exhaustion is a condition whose symptoms may include heavy sweating and a rapid pulse as a result of the body overheating. It's one of three heat-related syndromes, with heat cramps being the mildest and heatstroke being the most severe. Older adults may also be at risk due to medications they are taking that lead to electrolyte imbalances for treatment of medical co-morbidities.The young construction worker is at risk, but is not the one at highest risk. These workers will typically have a "thirst" response and will keep hydrated as needed. The police officer is a young adult who is probably in an acceptable state of fitness. The swimming instructor may also be at risk but has the ability to cool off rapidly by getting into the water.

Clients who have been admitted to the emergency department (ED) are assessed by the ED triage nurse for an oncoming shift. Which client is most appropriate to assign to an LPN/LVN? A client with heat exhaustion, receiving an IV of normal saline, with normal chemistry laboratory results and a temperature of 98.6° C (37° C) A client reporting right forearm swelling secondary to a "bug bite" with capillary refill in the right hand of greater than 3 seconds A client who was hiking and is now confused, and has crackles throughout all lung fields A client stung by an unknown insect who reports shortness of breath

A client with heat exhaustion, receiving an IV of normal saline, with normal chemistry laboratory results and a temperature of 98.6° C (37° C) It is appropriate to assign an LPN/LVN to care for the stable, heat exhaustion client who is already receiving appropriate treatment.The data from the other three clients all support the need for ongoing assessment and intervention by an RN. The client who presents with vascular instability and compromise needs quick intervention. The client who has an unclear picture at present but has the potential to deteriorate rapidly and the client with the unknown insect bite also need assessment by the RN.

An emergency department nurse assesses a client admitted after a lightning strike. Which assessment should the nurse complete first? a. Electrocardiogram (ECG) b. Wound inspection c. Creatinine kinase d. Computed tomography of head

ANS: A Clients who survive an immediate lightning strike can have serious myocardial injury, which can be manifested by ECG and myocardial perfusion abnormalities. The nurse should prioritize the ECG. Other assessments should be completed but are not the priority.

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 carotid pulse.

ANS: A In this emergency situation, the nurse should immediately initiate airway clearance and ventilator support measures, including delivering rescue breaths.

A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed? a. I can go swimming all by myself because I am a certified lifeguard. b. I cannot leave my toddler alone in the bathtub for even a minute. c. I will appoint one adult to supervise the pool at all times during a party. d. I will make sure that there is a phone near my pool in case of an emergency.

ANS: A People should never swim alone, regardless of lifeguard status. The other statements indicate good understanding of the teaching.

A provider prescribes a rewarming bath for a client who presents with partial-thickness frostbite. Which action should the nurse take prior to starting this treatment? a. Administer intravenous morphine. b. Wrap the limb with a compression dressing. c. Massage the frostbitten areas. d. Assess the limb for compartment syndrome.

ANS: A Rapid rewarming in a water bath is recommended for all instances of partial-thickness and full-thickness frostbite. Clients experience severe pain during the rewarming process and nurses should administer intravenous analgesics.

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 minimental state examination. c. Prepare the client for computed tomography of the brain. d. Request a psychiatric consult.

ANS: A The client is exhibiting signs of mountain sickness and high altitude cerebral edema (HACE). Dexamethasone (Decadron) reduces cerebral edema by acting as an anti-inflammatory in the central nervous system. The other interventions will not treat mountain sickness or HACE.

An emergency department nurse moves to a new city where heat-related illnesses are common. Which clients does the nurse anticipate being at higher risk for heat-related illnesses? (Select all that apply.) a. Homeless individuals b. Illicit drug users c. White people d. Hockey players e. Older adults

ANS: A, B, E Some of the most vulnerable, at-risk populations for heat-related illness include older adults; blacks (more than whites); people who work outside, such as construction and agricultural workers (more men than women); homeless people; illicit drug users (especially cocaine users); outdoor athletes (recreational and professional); and members of the military who are stationed in countries with hot climates (e.g., Iraq, Afghanistan).

A nurse teaches a client who has severe allergies to prevent bug bites. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Consult an exterminator to control bugs in and around your home. b. Do not swat at insects or wasps. c. Wear sandals whenever you go outside. d. Keep your prescribed epinephrine auto-injector in a bedside drawer. e. Use screens in your windows and doors to prevent flying insects from entering.

ANS: A, B, E To prevent arthropod bites and stings, clients should wear protective clothing, cover garbage cans, use screens in windows and doors, inspect clothing and shoes before putting them on, consult an exterminator, remove nests, avoid swatting at insects, and carry a prescription epinephrine auto-injector at all times if they are known to be allergic to bee or wasp stings.

A nurse is providing health education at a community center. Which instructions should the nurse include in teaching about prevention of lightning injuries during a storm? (Select all that apply.) a. Seek shelter inside a building or vehicle. b. Hide under a tall tree. c. Do not take a bath or shower. d. Turn off the television. e. Remove all body piercings. f. Put down golf clubs or gardening tools.

ANS: A, C, D, F When thunder is heard, shelter should be sought in a safe area such as a building or an enclosed vehicle. Electrical equipment such as TVs and stereos should be turned off. Stay away from plumbing, water, and metal objects. Do not stand under an isolated tall tree or a structure such as a flagpole. Body piercings will not increase a persons chances of being struck by lightning.

An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Administer oxygen via mask or nasal cannula. b. Administer ibuprofen, an antipyretic medication. c. Apply cooling techniques until core body temperature is less than 101 F. d. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. e. Obtain baseline serum electrolytes and cardiac enzymes.

ANS: A, D, E Heat stroke is a medical emergency. Oxygen therapy and intravenous fluids should be provided, and baseline laboratory tests should be performed as quickly as possible. The client should be cooled until core body temperature is reduced to 102 F. Antipyretics should not be administered.

A nurse is teaching a wilderness survival class. Which statements should the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.) a. Wear synthetic clothing instead of cotton to keep your skin dry. b. Drink plenty of fluids. Brandy can be used to keep your body warm. c. Remove your hat when exercising to prevent the loss of heat. d. Wear sunglasses to protect skin and eyes from harmful rays. e. Know your physical limits. Come in out of the cold when limits are reached.

ANS: A, D, E To prevent hypothermia and frostbite, the nurse should teach clients to wear synthetic clothing (which moves moisture away from the body and dries quickly), layer clothing, and wear a hat, facemask, sunscreen, and sunglasses. The client should also be taught to drink plenty of fluids, but to avoid alcohol when participating in winter activities. Clients should know their physical limits and come in out of the cold when these limits have been reached.

A provider prescribes diazepam (Valium) to a client who was bitten by a black widow spider. The client asks, What is this medication for? How should the nurse respond? a. This medication is an antivenom for this type of bite. b. It will relieve your muscle rigidity and spasms. c. It prevents respiratory difficulty from excessive secretions. d. This medication will prevent respiratory failure.

ANS: B Black widow spider venom produces a syndrome known as latrodectism, which manifests as severe abdominal pain, muscle rigidity and spasm, hypertension, and nausea and vomiting. Diazepam is a muscle relaxant that can relieve pain related to muscle rigidity and spasms. It does not prevent respiratory difficulty or failure.

A nurse plans care for a client admitted with a snakebite to the right leg. With whom should the nurse collaborate? a. The facilitys neurologist b. The poison control center c. The physical therapy department d. A herpetologist (snake specialist)

ANS: B For the client with a snakebite, the nurse should contact the regional poison control center immediately for specific advice on antivenom administration and client management.

A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. Which action should the nurse take first? a. Reposition the client into a prone position. b. Administer warmed intravenous fluids to the client. c. Wrap the clients extremities in warm blankets. d. Initiate extracorporeal rewarming via hemodialysis.

ANS: B Moderate hypothermia manifests with muscle weakness, increased loss of coordination, acute confusion, apathy, incoherence, stupor, and impaired clotting. Moderate hypothermia should be treated by core rewarming methods, which include administration of warm IV fluids, heated oxygen, and heated peritoneal, pleural, gastric, or bladder lavage, and by positioning the client in a supine position to prevent orthostatic changes. The clients trunk should be warmed prior to the extremities to prevent peripheral vasodilation. Extracorporeal warming with cardiopulmonary bypass or hemodialysis is a treatment for severe hypothermia.

On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1 F (40.1 C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurse take? a. Encourage the client to drink cool water or sports drinks. b. Start an intravenous line and infuse 0.9% saline solution. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Encourage rest and re-assess in 15 minutes.

ANS: B The client demonstrates signs of heat stroke. This is a medical emergency and priority care includes oxygen therapy, IV infusion with 0.9% saline solution, insertion of a urinary catheter, and aggressive interventions to cool the client, including external cooling and internal cooling methods. Oral hydration would not be appropriate for a client who has symptoms of heat stroke because oral fluids would not provide necessary rapid rehydration, and the confused client would be at risk for aspiration. Acetaminophen would not decrease this clients temperature or improve the clients symptoms. The client needs immediate medical treatment; therefore, rest and re-assessing in 15 minutes is inappropriate.

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. Assess temperature and for signs of fever. b. Check the clients creatinine kinase level. c. Ask about allergies to pineapple or papaya. d. Inspect the skin for signs of urticaria (hives).

ANS: C CroFab is an antivenom for pit viper snakebites. Clients should be assessed for hypersensitivity to bromelain (a pineapple derivative), papaya, and sheep protein prior to administration. During and after administration, the nurse should assess for urticaria, fever, and joint pain, which are signs of serum sickness.

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. Cardiopulmonary status d. Electrocardiogram rhythm

ANS: C Manifestations of coral snake envenomation are the result of its neurotoxic properties. The physiologic effect is to block neurotransmission, which produces ascending paralysis, reduced perception of pain, and, ultimately, respiratory paralysis. The nurse should monitor for respiratory rate and depth. Severe swelling and clotting problems do not occur with coral snakes but do occur with pit viper snakes. Electrocardiogram rhythm is not affected by neurotoxins.

After teaching a client how to prevent altitude-related illnesses, a nurse assesses the clients understanding. Which statement indicates the client needs additional teaching? a. If my climbing partner cant 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.

ANS: C Teaching to prevent altitude-related illness should include descending when symptoms start, staying hydrated, and taking acetazolamide (Diamox), which is commonly used to prevent and treat acute mountain sickness. The client should be taught to sleep at a lower elevation.

A nurse assesses a client admitted with a brown recluse spider bite. Which priority assessment should the nurse perform to identify complications of this bite? a. Ask the client about pruritus at the bite site. b. Inspect the bite site for a bluish purple vesicle. c. Assess the extremity for redness and swelling. d. Monitor the clients temperature every 4 hours.

ANS: D Fever and chills indicate systemic toxicity, which can lead to hemolytic reactions, kidney failure, pulmonary edema, cardiovascular collapse, and death. Assessing for a fever should be the nurses priority. All other symptoms are normal for a brown recluse bite and should be assessed, but they do not provide information about complications from the bite, and therefore are not the priority.

While at a public park, a nurse encounters a person immediately after a bee sting. The persons lips are swollen, and wheezes are audible. Which action should the nurse take first? a. Elevate the site and notify the persons next of kin. b. Remove the stinger with tweezers and encourage rest. c. Administer diphenhydramine (Benadryl) and apply ice. d. Administer an EpiPen from the first aid kit and call 911.

ANS: D The clients swollen lips indicate that anaphylaxis may be developing, and this is a medical emergency. 911 should be called immediately, and the client transported to the emergency department as quickly as possible. If an EpiPen is available, it should be administered at the first sign of an anaphylactic reaction. The other answers do not provide adequate interventions to treat airway obstruction due to anaphylaxis.

The nurse is coordinating care for a client who was bitten by a black widow spider. Which nursing action is assigned to the LPN/LVN? Administering tetanus toxoid vaccine intramuscularly Assessing the client for neurologic changes Monitoring for respiratory compromise in the client Providing discharge instructions to the client when the family arrives

Administering tetanus toxoid vaccine intramuscularly Administration of intramuscular medication is within the scope of practice and education level of an LPN/LVN.Physical assessment and ongoing monitoring for complications, as well as client education and planning for discharge, are all actions that require broader education and scope of practice and would be done by an RN.

The RN working at a long-term-care facility places priority on providing interventions for which resident? A 65-year-old paraplegic man who is demanding to see the health care provider about insurance benefits A 76-year-old woman with a total hip replacement who is showering for the first time since entering rehabilitation after surgery An 80-year-old man with congestive heart failure (CHF) who is outdoor for some "fresh air" when the temperature is 95° F (35° c An 82-year-old woman with dementia who is requesting "something" for a headache

An 80-year-old man with congestive heart failure (CHF) who is outdoor for some "fresh air" when the temperature is 95° F (35° C) The nurse's priority would be to intervene on behalf of the elderly CHF resident. The 80-year-old resident is outside when it is 95° F (35° C) and needs to be assisted back indoors with some alternatives provided for him to receive some "fresh air." This will help him meet his personal desires as well as maintain his safety and prevent potential heat-related illness.Although the 65-year-old paraplegic man has valid concerns, these concerns are not the nurse's highest priority in the group. The 76-year-old woman with a total hip replacement needs to be handled carefully and safely during a new activity, but she is not the nurse's greatest priority resident. Although the 82-year-old woman with dementia has a valid request, she is not the nurse's highest priority in this scenario.

The nurse is directing the care of a newly admitted client who is severely hypothermic. What does the nurse advise the rapid response team (RRT) to do first? Apply electrocardiographic (ECG) monitor leads to monitor cardiac activity. Draw blood samples to rule out coagulation problems. Insert a nasogastric tube for rewarming purposes. Obtain intravenous (IV) access to provide fluids and administer drugs.

Apply electrocardiographic (ECG) monitor leads to monitor cardiac activity. The nurse will advise the RRT to first place ECG leads on the client in order to monitor cardiac activity. People who are hypothermic are at risk for lethal cardiac dysrhythmias and need continual monitoring.Samples for laboratory testing and IV access would be implemented rapidly. Medications may not be effective until a client is normothermic, however warmed fluids may be administered to hasten the process. The same is true of inserting a nasogastric (NG) or orogastric (OG) tube as a means to rewarm the client.

A young client comes to the emergency department (ED) after being bitten by a scorpion on the playground at school. Which action does the nurse perform first? Administer a tetanus shot. Apply an ice pack to the sting site. Assess the client's vital signs. Call the poison control center.

Assess the client's vital signs. The first priority for the nurse to perform is vital sign assessment and continuous monitoring for several hours. This is done in the hospital ED or critical care unit to enable rapid intervention if symptoms progress.Although important, a tetanus shot and ice packs are not the immediate priority. Calling the poison control center is a secondary priority. This client may also benefit from transfer to a pediatric facility, if one is available.

After receiving a change-of-shift report, the client with which condition would be assessed by the emergency department (ED) nurse first? Bee sting on the jawline with an inability to swallow Bite on the hand from a stray dog with minimal bleeding Severe muscle cramps after running Suspected spider bite with a red and swollen forearm

Bee sting on the jawline with an inability to swallow The nurse would first assess the client who was stung by a bee and is unable to swallow. This client is showing potential signs of respiratory compromise and needs immediate assessment and intervention.Neither the client with the spider bite nor the dog bite client have life-threatening injuries. The current tetanus immunization status would be checked for each client and administered if needed. The client bitten by the dog might also require rabies vaccination follow-up. The client with muscle cramping after running would need to be assessed thoroughly for the potential of heat-related injury although this does not appear to be a life threat at this time.

On a hot summer day, an older adult is found by a neighbor lying on the floor, agitated and confused. After calling 911, the neighbor places ice bags on the client's groin area and armpits. Upon arrival at the hospital, which action does the emergency department (ED) nurse perform first? Administer two acetylsalicylic acid (aspirin) tablets orally. Check the client's airway and administer high-flow oxygen therapy. Monitor the client's vital signs. Place a cooling blanket on the client.

Check the client's airway and administer high-flow oxygen therapy. The first action made by the ED nurse is to check the client's airway and give high-flow oxygen therapy. Once in a clinical setting, the nurse monitors and supports the client's airway, breathing, and circulatory status. High-concentration oxygen therapy and IV lines with 0.9% saline solution are also indicated.This client is at risk for aspiration. Nothing would be given by mouth when a client is at risk for aspiration. Vital signs must be monitored, but they are not the immediate priority in this scenario. Use of a cooling blanket is important although not a top priority, especially if ice bags are already in place.

The nurse is providing reminders to a Red Cross class about safety procedures to prevent drowning. In which situation does this present the greatest risk? A couple going swimming together at a local lake Children swimming at the community pool College students going to a party at a boat house Families going to the quarry to swim

College students going to a party at a boat house The college party at the boat house is the situation that poses the greatest risk for drowning, due to the potential presence of alcohol or other mood-altering substances. The use of alcoholic beverages when swimming, boating, or near water increases the risk of water-related injuries and death.The couple swimming in the local lake is using the "buddy system." This situation does not present the greatest risk. Community pools frequently have life guards and safety equipment present. Because adults will be present at the quarry, this situation does not present the greatest risk.

While on the school playground, a child is stung by a bee, resulting in redness and swelling. The school nurse is nearby when it happens. What does the nurse do first? Apply an ice pack to the stinger. Gently scrape out the stinger with a credit card. Inject the child with an epinephrine pen (EpiPen auto-injector). Remove the bee and save it for identification.

Gently scrape out the stinger with a credit card. The nurse first needs to quickly remove the stinger by gently scraping or brushing it off with the edge of a knife blade, credit card, or needle.Once the stinger is removed, applying an ice pack to the area may decrease the pain in the area as well as venom distribution. Unless the child has had an allergic reaction in the past, an epinephrine pen would not be used. The bee does not need to be saved for identification.

The nurse is caring for a client who was admitted after a diving accident in a lake. Which task is appropriate to delegate to an experienced unlicensed assistive personnel (UAP)? Assessing the client's lung sounds and neurologic status Drawing arterial blood gases (ABGs) and phoning results to the health care provider Helping to maintain cervical spine stability during transfer to a stretcher Notifying the flight team of a possible transfer

Helping to maintain cervical spine stability during transfer to a stretcher Transferring and positioning clients is included in a UAP's education and scope of practice. An experienced UAP would be able to help with maintenance of cervical spine stability while under the supervision of licensed nursing staff.Nursing activities such as making assessments, arranging for client transfers, and communicating laboratory results to the health care provider require broader education and scope of practice and must be done by an RN. The actual drawing of ABGs is usually done by a respiratory therapist.

A client presents to a clinic stating, "I got bit by something cleaning out the shed." On assessment, the nurse notices a bite mark with a bluish-purple center on the client's posterior calf. What treatment would the nurse anticipate as first line care? Application of ice to bite Elevation of affected extremity Initiation of transfer to trauma center Localized wound care

Localized wound care The nurse would anticipate localized wound care as first line care for this client. A brown recluse spider bite is characterized by a wound that develops a bluish-purple center. Since the bite has already developed a dark center, this type of wound care needs to be initiated as soon as possible.Although cold compresses are beneficial initially, applying ice directly to a wound would potentially cause more tissue damage. Elevation of the extremity is more beneficial in the early stages immediately after the bite. This client does not require transfer to a trauma center for surgical intervention at this time, although the bite must be monitored for further tissue destruction and the need for debridement.

A hiker begins to feel ill within 48 hours after arriving at a resort in Colorado. Symptoms include poor activity tolerance, tachycardia, tachypnea, and a dry cough. Which treatment provides the most effective relief for this hiker? Acetazolamide sodium (Diamox) Dexamethasone (Decadron) Lower altitude Oxygen therapy

Lower altitude The most effective intervention to manage serious altitude-related illness is gradual descent to a lower altitude.Diamox needs to be taken before and during the trip for prevention, but will not help after symptoms of altitude-related illness have begun. Decadron can be administered during descent to help with symptoms, but is not the most effective treatment at this time. Oxygen is not the most effective treatment.

Which medications are contraindicated with a scorpion sting? Select all that apply. Acetaminophen (Tylenol) Barbiturates Benzodiazepines Opiates Tetanus toxoid

Medications contraindicated for a client with a scorpion sting include barbiturates, benzodiazepines, and opiates. These medications need to be avoided in clients with a scorpion sting because they can cause a loss of airway reflexes and can precipitate respiratory airway failure.It is safe to administer Tylenol to a client with a scorpion sting for fever and pain. Because the scorpion sting is a puncture wound, tetanus toxoid would be administered.

While at a soccer match, a player drops to the ground with heat exhaustion and a diminished level of consciousness. After ensuring the ABC's are intact, what does the team nurse do first? Give salt tablets. Move the player to the shade. Place ice packs under the arms. Provide a cool electrolyte fluid drink.

Move the player to the shade. After ensuring the ABC's are intact, the nurse would first move the player into the shade.After the player is in the shade, the nurse would place ice packs under the arms as well as in the groin to cool the client. Due to a diminished level of consciousness, nothing would be given by mouth to prevent aspiration. Salt tablets are not given.

A golfer who is caught in a thunderstorm is struck by lightning. A fellow golfer, who is a nurse, runs to the victim's aid. What does the nurse do initially? Apply a dressing over the skin burn where the lightning entered. Instruct everyone to not to touch the victim to avoid being hurt. Immediately begin cardiopulmonary resuscitation. Palpate to check for the presence of a pulse.

Palpate to check for the presence of a pulse. Initially, the nurse would palpate to check for the presence of a pulse.The most lethal initial effect of the massive current discharge of lightning on the cardiopulmonary system is cardiac arrest.If the client does not have a pulse, CPR will be started utilizing BLS protocols. The golfer is not electrically charged so he/she is not a danger to anyone else. The skin burn can be dressed when everyone is in a safe location from further lightning strikes.

A high school athlete recently suffered heat exhaustion. The school nurse is instructing the student on how to prevent a recurrence of this situation. Which student statement demonstrates that the nurse's teaching has been effective? "I should try to exercise between noon and 3 PM." "I will limit my fluids to drinking 'sports' drinks after I exercise." "Taking frequent rests is important when in a hot environment." "Wearing dark-colored clothing to deflect the sun away from me will help me stay cooler."

Taking frequent rests is important when in a hot environment." The statement that demonstrates that the teaching about heat exhaustion is effective is the comment that stresses the importance of frequent rest periods when in a hot environment. Frequent rest periods will decrease the risk of heat exhaustion.Exercising during times of peak sun exposure (midday) will increase the risk of heat exhaustion. Fluids, particularly water, have to be consumed throughout the exercise period and not be limited to a certain type. Light colored clothing, not dark, reflects the sun away from the individual.