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A fire is reported in the kitchen on the first floor of a three-floor community hospital, and the operator notifies the charge nurse on the third floor to start evacuation procedures. Which intervention should the charge nurse implement?
- A. Instruct unlicensed assistive personnel (UAPs) to transfer all non-ambulatory clients via wheelchairs.
- B. Instruct the nursing staff to evacuate ambulatory clients to the nearest fire exits.
- C. Shut all doors to client rooms and tell everyone to stay in their rooms until the fire department arrives.
- D. Announce in a calm voice that all visitors should proceed immediately to the first floor via the service elevators.
Correct Answer: C
Rationale: Shutting doors and keeping everyone in rooms follows the RACE protocol (Rescue, Alarm, Contain, Extinguish), containing the fire and protecting from smoke. Evacuating clients or using elevators during a fire risks exposure to danger.
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To help prevent by a dissatisfied client, which objective is most important to include in the orientation classes for staff nurses? New nursing staff members will
- A. demonstrate how to complete an adverse occurrence or variance report.
- B. discuss how to handle complaints from clients and/or their families.
- C. describe how to obtain legal services if needed.
- D. maintain personal malpractice insurance.
Correct Answer: B
Rationale: Teaching nurses to handle complaints effectively can prevent escalation to litigation by resolving conflicts early. Completing variance reports, obtaining legal services, or maintaining insurance are important but less preventive than addressing complaints directly.
The charge nurse of a critical care unit must transfer a client to a general unit to make a bed available for an incoming trauma client. Based on the information provided, which client is best for the nurse to recommend for transfer to the general unit?
- A. Subtotal thyroidectomy performed one hour ago, receiving a unit of packed red blood cells.
- B. Combined partial and full-thickness burns on the anterior chest three days ago. O2 saturation is 92%.
- C. Renal transplant yesterday, complaining of flank pain and who states, 'it's hot in here.'
- D. Nephrotic syndrome diagnosed 2 days ago, decreased serum protein level and mild edema.
Correct Answer: D
Rationale: The client with nephrotic syndrome is relatively stable, requiring routine care suitable for a general unit. The other clients have acute, unstable conditions requiring critical care monitoring.
A client with tachycardia and hypotension presents to the emergency department (ED) reporting severe vomiting and diarrhea for three days. Which action is most important for the nurse to implement?
- A. Monitor for impending signs of shock.
- B. Initiate enteric precaution procedures.
- C. Reduce light, noise and temperature.
- D. Encourage electrolyte supplements.
Correct Answer: A
Rationale: Monitoring for signs of shock is critical due to the client's dehydration and fluid volume deficit, which could lead to organ failure. Enteric precautions, environmental adjustments, and electrolyte supplements are important but secondary to preventing life-threatening shock.
Which client requires the most immediate intervention by the nurse?
- A. An older adult receiving enteral feedings via feeding tube who has a temperature of 100.6°F (38.1°C).
- B. A client with acute kidney injury who is somnolent and does not respond to verbal commands.
- C. A young adult who experienced heat stroke and is receiving a normal saline intravenous (IV) fluid bolus.
- D. A pregnant client with hyperemesis gravidarum who is receiving an infusion of Ringer's Lactate.
Correct Answer: B
Rationale: The client with acute kidney injury and unresponsiveness likely has uremic encephalopathy, a life-threatening condition requiring immediate intervention. The other clients' conditions are less urgent as they are receiving appropriate treatments.
The nurse manager decides to report a staff nurse to the Peer Review Committee (PRC). Which activity merits this action?
- A. Administered two medications to the same client at the wrong time.
- B. Documented data in the clinical record before assessing client's condition.
- C. Served a diet tray to a client who was NPO for a scheduled procedure.
- D. Changed work assignments without prior approval from charge nurse.
Correct Answer: B
Rationale: Falsifying documentation by recording data before assessment is a serious ethical breach, warranting PRC review. Medication errors, serving a tray, or changing assignments are less severe and can be addressed through counseling.