A nurse is the first responder to the scene of a multi-vehicle accident on the highway. Which of the following is the priority nursing action?

Correct Answer: D

Rationale: The correct answer is D: Ensure the safety of the scene. This is the priority nursing action because without ensuring scene safety, further harm could occur to both the nurse and the injured clients. By securing the scene, the nurse prevents additional accidents or injuries. This action also allows for a safer environment for providing medical care. Summary: A: Beginning immediate medical care is important, but safety of the scene should be ensured first. B: Blocking oncoming traffic may help prevent further accidents, but safety of the scene is the priority. C: Waiting for all ambulances is not ideal as immediate action is necessary to prevent further harm.

Correct Answer: B

Rationale: The correct answer is B: Bacteria. Bacteria are the most common cause of wound infections, especially in surgical wounds. They can easily enter the body during surgery and cause infections. Viruses typically do not cause wound infections, as they require living cells to replicate. Fungi are less common in wound infections and are usually associated with specific risk factors. Spores are not a common cause of wound infections, as they are usually dormant and require specific conditions to germinate. In summary, bacteria are the most likely cause of the infection in the client's wound due to their ability to easily enter the body during surgery and cause infections.

Correct Answer: A

Rationale: The correct answer is A: direct contact. Mononucleosis is commonly spread through the exchange of saliva, such as kissing or sharing utensils. Direct contact allows for the transmission of the infectious organisms directly from one person to another. Indirect contact (B) involves transmission through contaminated objects, which is not the primary mode of transmission for mononucleosis. Airborne route (C) is when pathogens are spread through the air, which is not typical for mononucleosis. Vectors (D) are organisms that can transmit disease but are not involved in the transmission of mononucleosis.

Correct Answer: C

Rationale: The correct answer is C: Immune response. The immune system is the body's defense mechanism against infections. It recognizes and fights off pathogens like bacteria, viruses, and other harmful substances. The immune response involves various cells and proteins working together to neutralize and eliminate the invading pathogens. Racial characteristics (A) and body shape and size (B) are not directly related to the body's defense against infections. Level of susceptibility (D) may influence an individual's likelihood of getting infected but does not represent an active defense mechanism like the immune response does.

Correct Answer: D

Rationale: The correct answer is D: Urinary catheterization. This procedure carries the greatest risk for a nosocomial infection due to the direct introduction of pathogens into the urinary tract. Steps in catheterization involve breaching the body's natural defense barriers, increasing susceptibility to infections. The other choices (A: Enema, B: Intramuscular injections, C: Heat lamp) do not involve invasive procedures like catheterization, which significantly elevate the risk of nosocomial infections. Enemas and intramuscular injections are typically sterile procedures, while the heat lamp does not involve direct entry into the body, thus posing a lower risk of infection compared to urinary catheterization.