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A nurse enters a client's room and notices a small fire in the bathroom trash can. The nurse removes the client from the room. Which of the following actions should the nurse take next?
- A. Activate the fire alarm.
- B. Close the fire doors and the doors to the clients' rooms.
- C. Remove all clients from the unit.
- D. Extinguish the fire.
Correct Answer: A
Rationale: The correct answer is A: Activate the fire alarm. This is the most critical step as it alerts others in the facility to the fire, ensuring swift evacuation and response from the fire department. Closing fire doors (choice B) and removing all clients from the unit (choice C) are important steps but should be done after the fire alarm is activated. Attempting to extinguish the fire (choice D) before ensuring everyone's safety is not recommended as it can put the nurse and clients at risk.
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A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the following statements by the client should the nurse identify as an indication that a referral to an occupational therapist is necessary?
- A. I'm having difficulty climbing the stairs at my house.
- B. I am tired of having pain in my joints all the time.
- C. I will need assistance with bathing.
- D. I need some help planning my meals to maintain my weight.
Correct Answer: C
Rationale: Difficulty with bathing, an activity of daily living, indicates a need for occupational therapy to address functional limitations.
A nurse is reviewing the plan of care for a child who has oppositional defiant disorder. Which of the following members of the interprofessional health care team should the nurse plan to consult?
- A. Physical therapist
- B. Social worker
- C. Occupational therapist
- D. Speech pathologist
Correct Answer: B
Rationale: The correct answer is B: Social worker. A social worker is essential in addressing the psychosocial aspects of oppositional defiant disorder, providing support to the child and family, and coordinating resources. Physical therapist (A) focuses on physical rehabilitation, occupational therapist (C) on activities of daily living, and speech pathologist (D) on communication issues, which are not the primary concerns in oppositional defiant disorder.
A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend?
- A. Pharmacist
- B. Respiratory therapist
- C. Social worker
- D. Child protective services
Correct Answer: C
Rationale: A social worker can connect the family with financial resources to obtain the nebulizer, addressing the affordability issue.
A nurse is participating on a committee that is considering the creation of a policy that will allow nurses to remove chest tubes. Which of the following is an appropriate resource for the nurse to consult in planning for this policy?
- A. State nurse practice act
- B. ANA Standards of Practice
- C. ANA Code of Ethics
- D. Institute of Medicine
Correct Answer: A
Rationale: The correct answer is A: State nurse practice act. The state nurse practice act outlines the scope of practice for nurses within a specific state, including the tasks they can perform. Removing chest tubes is a clinical procedure that falls within the scope of nursing practice. Consulting the state nurse practice act ensures that nurses are adhering to the legal and regulatory standards when performing such procedures.
B: ANA Standards of Practice focuses on the general standards of nursing practice but may not provide specific guidance on chest tube removal.
C: ANA Code of Ethics pertains to ethical principles in nursing and does not provide specific guidelines for clinical procedures like chest tube removal.
D: Institute of Medicine focuses on healthcare quality and safety but does not provide specific guidance on nursing procedures.
Therefore, the state nurse practice act is the most appropriate resource for the nurse to consult in planning for the policy on chest tube removal.
A charge nurse notices that staff nurses are having difficulty using new IV infusion pumps for medication administration. Which of the following is the priority action by the charge nurse?
- A. Assess the staff nurses' knowledge deficit.
- B. Demonstrate use of the pump during medication administration.
- C. Plan an in-service education program on the unit.
- D. Pair an inexperienced nurse with an experienced nurse.
Correct Answer: A
Rationale: The correct answer is A: Assess the staff nurses' knowledge deficit. This is the priority action because it helps identify the root cause of the difficulty with the new IV infusion pumps. By assessing the staff nurses' knowledge deficit, the charge nurse can determine if additional training, education, or support is needed. This step is crucial in addressing the problem effectively and ensuring safe medication administration.
Other choices:
B: Demonstrating the use of the pump during medication administration may be helpful but should come after assessing the knowledge deficit.
C: Planning an in-service education program is important but should be based on the assessment of the staff nurses' knowledge deficit.
D: Pairing an inexperienced nurse with an experienced nurse may be beneficial but does not directly address the underlying issue of knowledge deficit.