Nokea
A nurse is providing an in service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
- A. A client who uses a wheelchair and is confused
- B. A client who is bedridden and wears a hearing aid
- C. A client who is ambulatory and receiving oxygen
- D. A client who has a fracture and is in balance suspension traction
Correct Answer: A
Rationale: The correct answer is A because a client who uses a wheelchair and is confused is at the highest risk during a fire evacuation due to mobility limitations and decreased ability to follow instructions. Evacuating this client first ensures their safety and prevents potential delays in the evacuation process.
Choice B is incorrect because a bedridden client wearing a hearing aid can still be safely evacuated with assistance. Choice C is incorrect as an ambulatory client receiving oxygen can usually move independently and should be evacuated after the client in a wheelchair. Choice D is incorrect because a client with a fracture in traction can be safely moved with proper equipment and should not be the first priority for evacuation.
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A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the following actions should the nurse take?
- A. Wait 1 day to collect the specimen if the client cannot provide sputum.
- B. Wear sterile gloves to collect the specimen from the client.
- C. Ask the client to provide 15 to 20 mL of sputum into the container
- D. Obtain the specimen immediately upon the client waking up.
Correct Answer: D
Rationale: The correct answer is D: Obtain the specimen immediately upon the client waking up. This is the correct action because sputum is most concentrated in the morning, making it easier to collect a good sample for testing. Waiting 1 day (A) can delay treatment. Wearing sterile gloves (B) is important but not specific to sputum collection. Asking for 15-20mL of sputum (C) is appropriate, but the timing of collection is crucial.
A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?
- A. You should consider taking a sleeping pill before bed each night.'
- B. It is always difficult caring for someone who is terminally ill.'
- C. I am sure you're doing a great job taking care of your mother.'
- D. I can give you information about respite care if you are interested.'
Correct Answer: D
Rationale: The correct response is D: "I can give you information about respite care if you are interested." This is the best response because it addresses the son's lack of sleep, which is a common issue for family caregivers. Offering information about respite care can provide the son with the opportunity to take a break and get some rest while ensuring his mother's needs are still met. It shows empathy and support for his situation.
Choice A is incorrect because suggesting a sleeping pill does not address the underlying issue of caregiver stress and may not be the best solution. Choice B is incorrect as it is a general statement and does not offer any practical help or support. Choice C, while supportive, does not provide a solution to the son's lack of sleep.
A nurse is assessing a client who has histrionic personality disorder. Which of the following manifestations should the nurse expect?
- A. Suspicious of others
- B. Callousness
- C. Self-centered behavior
- D. Violates other's rights
Correct Answer: C
Rationale: The correct answer is C: Self-centered behavior. Individuals with histrionic personality disorder typically exhibit attention-seeking, dramatic, and overly emotional behaviors. They often crave approval and validation from others, focusing on themselves and their own needs. This behavior aligns with the core characteristics of histrionic personality disorder.
Choice A (Suspicious of others) is incorrect as suspicion is not a defining trait of histrionic personality disorder. Choice B (Callousness) is inconsistent as histrionic individuals tend to be overly emotional rather than callous. Choice D (Violates other's rights) is not a common feature of histrionic personality disorder.
In summary, the nurse should expect self-centered behavior in a client with histrionic personality disorder, as they typically display attention-seeking and dramatic behaviors, seeking validation and approval from others.
A nurse is preparing to initiate intravenous fluids via infusion pump for a client. Which of the following actions should the nurse take?
- A. Obtain a surge protector that can accommodate the pump and several other appliances
- B. Verify that the extension cord for the pump is ungrounded
- C. Report the pump has a frayed cord and proceed with the infusion
- D. Check the expiration date on the safety inspection sticker of the pump
Correct Answer: D
Rationale: The correct answer is D: Check the expiration date on the safety inspection sticker of the pump. This is crucial for ensuring the safety and efficacy of the pump. Checking the expiration date ensures that the pump has been recently inspected and is functioning properly, reducing the risk of malfunctions.
A: Obtaining a surge protector is important for electrical safety, but it is not directly related to the specific task of initiating intravenous fluids via an infusion pump.
B: Verifying that the extension cord is ungrounded is unsafe as it increases the risk of electrical hazards.
C: Reporting a frayed cord is essential for patient safety, but proceeding with the infusion without addressing the issue is dangerous.
E, F, G: No information provided.
A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively?
- A. Delegate tasks to the AP
- B. Determine goals of the day.
- C. Develop an hourly time frame for tasks
- D. Schedule daily activities
Correct Answer: B
Rationale: The correct answer is B: Determine goals of the day. This is the first step to managing time effectively as it helps prioritize tasks and establish a clear direction for care delivery. By setting goals, the nurse can focus on important tasks, delegate appropriately, and allocate time efficiently.
A: Delegating tasks to the AP can come after determining goals to ensure tasks are aligned with priorities.
C: Developing an hourly time frame for tasks can be done once goals are established to create a detailed schedule.
D: Scheduling daily activities is important but should be based on the goals set for the day.
In summary, determining goals of the day is the initial step in time management as it provides a framework for prioritizing tasks and organizing activities efficiently.