Nokea
A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
- A. A client who is receiving heparin for deep-vein thrombosis.
- B. A client who is 1 day postoperative following a vertebroplasty.
- C. A client who has cancer and a sealed implant for radiation therapy.
- D. A client who has COPD and a respiratory rate of 44/min.
Correct Answer: B
Rationale: The correct choice is B: A client who is 1 day postoperative following a vertebroplasty. This client is the most stable among the options provided. Early discharge is appropriate because the client is 1 day postoperative, likely past the critical immediate postoperative period. Discharging this client will create space for incoming emergency admissions. Choice A should not be discharged early as managing deep-vein thrombosis with heparin requires close monitoring to prevent complications. Choice C should not be discharged early due to the need for ongoing cancer treatment. Choice D should not be discharged early as the client with COPD and a high respiratory rate of 44/min requires close monitoring and intervention to prevent respiratory distress.
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A home health nurse manager is caring for a client who has methicillin-resistant Staphylococcus aureus. Which of the following actions should the nurse take?
- A. Remove fresh flowers from the client's home
- B. Wear a mask when within 3 feet of the client
- C. Encourage the client to use a HEPA filter in the house
- D. Double bag soiled dressing in polyethylene bags
Correct Answer: D
Rationale: The correct answer is D: Double bag soiled dressing in polyethylene bags. This is important to prevent the spread of methicillin-resistant Staphylococcus aureus (MRSA) to others. Double bagging the soiled dressing in polyethylene bags helps contain the bacteria and reduces the risk of transmission.
Choice A: Removing fresh flowers is not directly related to preventing the spread of MRSA.
Choice B: Wearing a mask within 3 feet of the client may not be effective in preventing MRSA transmission.
Choice C: Using a HEPA filter is not specifically targeted at preventing MRSA transmission.
In summary, choice D is correct because it directly addresses the prevention of MRSA transmission, while the other choices are not as directly related to this specific concern.
A first response team is working at the location of a bombing incident. A nurse triaging a group of clients should give treatment priority to which of the following clients?
- A. A client who has superficial partial-thickness burn injuries over 5% of his body
- B. A client who has a femur fracture with a 2+ pedal pulse
- C. A client who is ambulatory and exhibits manic behavior
- D. A client who has a rigid abdomen with manifestations of shock
Correct Answer: D
Rationale: The correct answer is D: A client who has a rigid abdomen with manifestations of shock. This client should receive treatment priority because a rigid abdomen can indicate internal bleeding or organ damage, which are life-threatening conditions requiring immediate medical attention to prevent further complications. Manifestations of shock, such as hypotension and tachycardia, also indicate a critical condition that needs urgent intervention to stabilize the client's condition and prevent deterioration.
Choice A is incorrect because superficial partial-thickness burn injuries, although painful and requiring treatment, are not immediately life-threatening compared to internal injuries like in choice D. Choice B is incorrect as a femur fracture with a palpable pedal pulse indicates distal circulation is intact, making it a lower priority compared to the critical condition in choice D. Choice C is incorrect as manic behavior, while concerning, does not pose an immediate threat to the client's life compared to the potentially life-threatening conditions in choice D.
A faith community nurse is preparing to meet with the family of an adolescent who has leukemia. Which of the following actions should the nurse plan to take?
- A. Focus the discussion on the adolescent's future career plans.
- B. Determine how the adolescent's health has affected family roles.
- C. Ask another family from the same faith congregation to attend the meeting for support.
- D. Direct conversation to the parents to avoid embarrassing the adolescent.
Correct Answer: B
Rationale: The correct answer is B: Determine how the adolescent's health has affected family roles. This is important because the nurse needs to understand the impact of the adolescent's illness on the family dynamics and roles. By assessing this, the nurse can provide appropriate support and resources to help the family cope effectively.
Choice A is incorrect because focusing on the adolescent's future career plans may not address the immediate concerns and emotional needs of the family facing a health crisis.
Choice C is incorrect as involving another family may not be appropriate without the consent of the adolescent and their family.
Choice D is incorrect because directing the conversation solely to the parents may exclude the adolescent from being an active participant in their own care and may not address their unique needs.
A nurse is discussing short- and long-term goals with a client who has alcohol use disorder and is being admitted to a treatment facility. Which of the following statements is appropriate for the nurse to include in the discussion?
- A. You will be taking a once-weekly dose of disulfiram to help control withdrawal symptoms during treatment
- B. Remaining physically active will help to minimize drowsiness and chills associated with initial alcohol withdrawal
- C. Attending Al-Anon meetings will help you identify a role model to assist you with making needed changes
- D. You will begin learning functional skills to replace defense mechanisms and behaviors while in treatment
Correct Answer: D
Rationale: Correct Answer: D: You will begin learning functional skills to replace defense mechanisms and behaviors while in treatment
Rationale: This statement is appropriate because it focuses on the core aspect of treatment for alcohol use disorder, which is addressing maladaptive coping mechanisms with healthier alternatives. By learning functional skills to replace defense mechanisms and behaviors, the client can develop healthier coping strategies and decrease the likelihood of relapse in the long term.
Summary of other choices:
A: Incorrect - Disulfiram is not used to control withdrawal symptoms; it is a deterrent medication to discourage alcohol consumption.
B: Incorrect - Physical activity is beneficial, but it does not directly address the underlying issues of alcohol use disorder.
C: Incorrect - Al-Anon meetings are for family and friends of individuals with substance use disorders, not for the individual seeking treatment.
E, F, G: No information provided.
A nurse is caring for a client who is having difficulty performing activities of daily living. The nurse is functioning in which of the following roles when arranging for an occupational therapist to visit the client?
- A. Administrator
- B. Nurse consultant
- C. Case manager
- D. Clinician
Correct Answer: C
Rationale: The correct answer is C: Case manager. In this scenario, the nurse is functioning as a case manager by coordinating and arranging for the occupational therapist to visit the client. A case manager is responsible for coordinating care services and resources for clients to meet their healthcare needs. A nurse consultant (B) provides expert advice and guidance but does not typically coordinate services like a case manager. An administrator (A) is in charge of managing the overall operations of a healthcare facility. A clinician (D) directly provides healthcare services to clients. In this situation, the nurse is not assuming these roles but rather acting as a case manager to ensure the client receives the necessary occupational therapy services.