Nokea
A home care nurse is visiting an older client recovering from a mild stroke affecting the left side. The client lives alone but receives regular assistance from the daughter and son, who both live within 10 miles. To assess for risk factors related to safety, which actions should the nurse take? Select all that apply.
- A. Assess the client's visual acuity.
- B. Observe the client's gait and posture.
- C. Evaluate the client's muscle strength.
- D. Look for any hazards in the home care environment.
- E. Ask a family member to move in with the client until recovery is complete.
- F. Request that the client transfer to an assisted living environment for at least 1 month.
Correct Answer: A,B,C,D
Rationale: To conduct a thorough client assessment, the nurse assesses for possible risk factors related to safety. The assessment should include assessing visual acuity, gait and posture, and muscle strength because alterations in these areas place the client at risk for falls and injury. The nurse should also assess the home environment, looking for any hazards or obstacles that would affect safety. Asking a family member to move in with the client until recovery is complete and requesting that the client transfer to an assisted living environment for at least 1 month are not assessment activities. Additionally, nothing in the question indicates that these actions are necessary; therefore, these options are unrealistic and unreasonable.
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At the scene of a train crash, the nurse triages the victims. Which clients should be coded for triage as most urgent or the first priority? Select all that apply.
- A. Is dead
- B. Has chest pain
- C. Has a leg sprain
- D. Has a chest wound
- E. Has multiple fractures
- F. Has full-thickness burns over 30% of the body
Correct Answer: B,D,F
Rationale: In a disaster situation, saving the greatest number of lives is the most important goal. During a disaster the nurse would triage the victims to maximize the number of survivors and sort the treatable from the untreatable victims. First priority victims (most urgent and coded red) have life-threatening injuries and are experiencing hypoxia or near hypoxia. Examples of injuries in this category are shock, chest wounds, internal hemorrhage, head injuries producing loss of consciousness, partial- or full-thickness burns over 20% of the body surface, and chest pain. Second priority victims (urgent and coded yellow) have injuries with systemic effects but are not yet hypoxic or in shock and can withstand a 2-hour wait without immediate risk (e.g., a victim with multiple fractures). Third priority victims (coded green) have minimal injuries unaccompanied by systemic complications and can wait for more than 2 hours for treatment (leg sprain). Dying or dead victims have catastrophic injuries, and the dying victims would not survive under the best of circumstances (coded black).
The nurse prepares a client being discharged from the hospital to receive oxygen therapy at home. Which action should the nurse include in client teaching about oxygen safety?
- A. Holding the oxygen tank on your lap when traveling
- B. Checking the oxygen level of the tank on a regular basis
- C. Lighting candles at least a few feet away from the oxygen tank
- D. Reporting low oxygen levels in the tank to the primary health care provider (HCP)
Correct Answer: B
Rationale: The nurse instructs the client and family to check the oxygen level in the tank on a regular basis to prevent the oxygen from running out. When traveling, the oxygen tank should be secured in place to prevent tank damage and a potentially devastating injury from a moving tank. Oxygen is a highly combustible gas, and, although it will not spontaneously burn or cause an explosion, it contributes to a fire if it contacts a spark from a cigarette, burning candle, or electrical equipment. The nurse instructs the client to contact the oxygen supplier about low oxygen levels in the tank; contacting the HCP is likely to delay prompt replacement of the oxygen tank.
The nurse is about to administer a prescribed intravenous dose of tobramycin when the client reports vertigo and ringing in the ears. Which action should the nurse take next?
- A. Check the client's pupillary responses.
- B. Hang the dose of medication immediately.
- C. Give a dose of droperidol with the tobramycin.
- D. Hold the dose and call the primary health care provider (HCP).
Correct Answer: D
Rationale: Tobramycin is an antibiotic (aminoglycoside). Ringing in the ears and vertigo are two symptoms that may indicate dysfunction of the eighth cranial nerve. The nurse should hold the dose and notify the HCP. Ototoxicity is a toxic effect of therapy with aminoglycosides and could result in permanent hearing loss. There is no need to check the pupillary response. Administering the dose would be an unsafe response.
Which clinical situation should justifiably be viewed as an assault?
- A. The nurse threatens to apply restraints to a client who is exhibiting aggressive behavior.
- B. The client requests a medical discharge, but the nurse physically forces the client to stay.
- C. The charge nurse sends an email to a staff member that includes a poor performance evaluation about another person.
- D. The nurse overhears the primary health care provider making derogatory remarks to the client about the nurse's level of competency.
Correct Answer: A
Rationale: An assault occurs when a person puts another person in fear of a harmful or offensive act. Battery involves offensive touching or the use of force by a perpetrator without the permission of the victim. Defamation takes place when a falsehood is said (slander) or written (libel) about a person that results in injury to that person's good name and reputation.
A delivery room nurse is preparing a client for a cesarean delivery. Which position will promote maximum uteroplacental perfusion during this surgery?
- A. Prone position
- B. Semi-Fowler's position
- C. Trendelenburg's position
- D. Supine position with a wedged right hip
Correct Answer: D
Rationale: Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities, thereby decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position, so a wedge placed under the right hip provides displacement of the uterus off of the vena cava. A semi-Fowler's or prone position is not practical for this type of abdominal surgery. Trendelenburg positioning places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation.