Nokea
A charge nurse is orienting a newly licensed nurse to the unit's emergency response procedures. Which of the following statements by the newly licensed nurse indicates a need for further teaching?
- A. I should pull the fire alarm if I see smoke in a client's room.
- B. I need to know the location of the nearest fire extinguisher.
- C. I can use an elevator to evacuate clients during a fire.
- D. I should close all doors to contain a fire on the unit.
Correct Answer: C
Rationale: Using an elevator during a fire is unsafe due to the risk of entrapment or power failure, indicating a need for further teaching. The other statements reflect correct fire safety protocols.
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A nurse is reviewing admission assessment and plan of care for a client who has Crohn's disease. Admission Assessment
A 20-year-old admitted through emergency department who is experiencing an exacerbation of previously diagnosed Crohn's disease. Client has lost 6.8 kg (15 lb) over the past week and is too nauseated to keep anything down today. They noticed blood in their stool three days ago. Repeatedly stated to staff, "I do not want to live like this. I am totally frustrated with all you medical people."
Assessment:
Right lower quadrant abdominal pain, abdominal bloating, diarrhea (mucus and blood present), perianal abscess.
Vital Signs:
Temperature 37.5° C (99.5° F)
Heart rate 78/min
Respiratory rate 20/min
Blood pressure 102/54 mm/Hg
Provider Prescriptions
Medical management
CBC, CMP. ESR (erythrocyte sedimentary rate)
MRE (magnetic resonance enterography) of pelvis and abdomen
Corticosteroids for clinical finding management. Taper dose as indicated.
Gastrointestinal evaluation
Nutritional screening and management
Screen for depression
Smoking cessation program
Follow CDC recommended immunizations for those on immunosuppressive therapies.
Evaluate for possible surgical management.
A nurse is reviewing admission assessment and plan of care for a client who has Crohn's disease. Which members of the interdisciplinary team should the nurse anticipate being included the plan of care? Select all that apply.
- A. Occupations Therapist
- B. General Surgeon
- C. Physical Therapist
- D. Radiologist
- E. Registered Dietitian
- F. Gastroenterologist
- G. Speech Therapist
Correct Answer: B,D,E,F
Rationale: The correct answer includes a General Surgeon, Radiologist, Registered Dietitian, and Gastroenterologist. General Surgeon is essential for surgical interventions in severe cases. Radiologist helps in diagnostic imaging. Registered Dietitian assists in managing the client's nutritional needs given the impact of Crohn's disease on digestion. Gastroenterologist specializes in treating gastrointestinal issues like Crohn's disease. The other choices are incorrect because: A) Occupational Therapist primarily focuses on helping individuals engage in meaningful activities, which may not be directly related to managing Crohn's disease. C) Physical Therapist focuses on physical rehabilitation, not the primary focus in managing Crohn's disease. G) Speech Therapist is not typically included in the interdisciplinary team for managing Crohn's disease.
A nurse is caring for four postoperative clients. The nurse can delegate obtaining vital signs to an assistive personnel (AP) for which of the following clients?
- A. A client who is 3 days postoperative following a craniotomy
- B. A client who is 3 days postoperative following gastric bypass surgery
- C. A client who is 2 hr postoperative following an abdominal hysterectomy
- D. A client who is 1 hr postoperative following a thyroidectomy
Correct Answer: B
Rationale: The correct answer is B because a client who is 3 days postoperative following gastric bypass surgery is stable and unlikely to have immediate complications. Vital signs can be safely delegated to an assistive personnel (AP) for this client.
Choice A is incorrect because a client who is 3 days postoperative following a craniotomy may still be at risk for neurological complications that require close monitoring by a nurse.
Choice C is incorrect because a client who is only 2 hours postoperative following an abdominal hysterectomy is still in the immediate postoperative period and requires frequent monitoring by a nurse.
Choice D is incorrect because a client who is only 1 hour postoperative following a thyroidectomy is in the immediate postoperative period and may have potential complications that require close monitoring by a nurse.
Overall, the key factor in delegating obtaining vital signs to an AP is the stability of the client's condition postoperatively.
A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. During transport to the facility, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the client's family. Which of the following actions should the nurse anticipate the neurosurgeon taking?
- A. Prescribing naloxone to reverse the effects of the morphine
- B. Asking the client to sign the surgical consent form
- C. Delaying the surgery until a member of the client's family is reached
- D. Invoking implied consent
Correct Answer: D
Rationale: The correct answer is D: Invoking implied consent. Implied consent allows healthcare providers to proceed with urgent treatment when a patient is unable to provide informed consent and there is an immediate threat to the patient's life or health. In this scenario, the client requires urgent surgical intervention for a compression fracture, and the family cannot be reached. Therefore, the neurosurgeon may invoke implied consent to proceed with the surgery to prevent further harm to the client.
A: Prescribing naloxone to reverse the effects of the morphine is not necessary in this case as the morphine was given for pain management and does not interfere with the need for urgent surgical intervention.
B: Asking the client to sign the surgical consent form is not appropriate as the client may not be in a condition to provide informed consent due to the urgent nature of the surgery and the effects of the medication.
C: Delaying the surgery until a member of the client's family is reached may not be feasible if there
A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first?
- A. An infant who has pertussis and is receiving oxygen via nasal cannula
- B. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions
- C. A school-age child who has diabetes mellitus and requires blood glucose monitoring
- D. A toddler who has both arms in casts and needs to be fed his breakfast
Correct Answer: A
Rationale: The correct answer is A. The nurse should assess the infant with pertussis receiving oxygen first because pertussis can cause severe respiratory distress. Assessing the infant's respiratory status is crucial as pertussis can lead to respiratory failure. Oxygen therapy is essential for maintaining adequate oxygenation levels. The nurse must monitor the infant's respiratory rate, effort, and oxygen saturation levels to ensure proper oxygenation. This assessment takes priority over the other clients' needs.
Choice B is incorrect because although the adolescent has sickle cell crisis, they are stable and ready for discharge instructions, which can be addressed after the critical assessment of the infant is completed.
Choice C is incorrect as monitoring blood glucose levels in a child with diabetes is important but does not take precedence over assessing a critically ill infant with pertussis.
Choice D is incorrect as feeding a toddler with both arms in casts can be challenging but does not pose an immediate threat to their health compared to the infant with pertussis requiring oxygen.
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A nurse is discussing emergency response with a newly licensed nurse. The nurse should identify which of the following as a triage officer during the time of a disaster?
- A. Nurses and other emergency medical personnel
- B. Responding law enforcement officers
- C. Members of the Federal Emergency Management Agency (FEMA)
- D. Representatives from the American Red Cross
Correct Answer: A
Rationale: The correct answer is A because nurses and other emergency medical personnel are trained to assess and prioritize patients based on their medical needs during a disaster. They have the expertise to quickly identify and categorize patients to ensure those with the most critical conditions receive immediate care. Responding law enforcement officers (B) focus on security and crowd control. Members of FEMA (C) are responsible for coordinating disaster response at a larger scale. Representatives from the American Red Cross (D) provide support services but do not typically serve as triage officers.