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A nurse in an emergency department is triaging four clients following a mass casualty event. To which of the following clients should the nurse assign a red tag?
- A. A client who experienced a brief loss of consciousness
- B. A client who has major burns covering 70% of their body
- C. A client who has fixed pupils
- D. A client who has a compromised airway
Correct Answer: D
Rationale: The correct answer is D: A client who has a compromised airway. Assigning a red tag indicates the client needs immediate attention and has life-threatening injuries. A compromised airway can lead to rapid deterioration and death if not addressed promptly, making it the priority. Brief loss of consciousness (A) may not indicate immediate danger. Major burns (B) require urgent care but may not lead to imminent death like an obstructed airway. Fixed pupils (C) suggest neurological issues but may not be immediately life-threatening. In this scenario, ensuring a patent airway is crucial for the client's survival, warranting a red tag assignment.
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A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the background portion of the report?
- A. A prescribed consultation
- B. The client's vital signs
- C. The client's name
- D. The client's code status
Correct Answer: D
Rationale: The correct answer is D: The client's code status. In the background portion of an SBAR report, the nurse should include the client's code status to inform the receiving unit about the client's preferences for resuscitation in case of an emergency. This information is crucial for providing appropriate and individualized care.
A: A prescribed consultation is typically included in the assessment or recommendations sections of the SBAR report, not the background.
B: The client's vital signs are typically included in the assessment section to provide current physiological data.
C: The client's name is already known and is not necessary in the background portion of the report.
E, F, G: These choices are not applicable to the background portion of the SBAR report.
A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first?
- A. Determine the reasons the nurses are not taking scheduled breaks.
- B. Provide coverage for the nurses' breaks.
- C. Review facility policies for taking scheduled breaks.
- D. Discuss time management strategies with the nurses.
Correct Answer: A
Rationale: Determining the reasons for not taking breaks identifies the root cause, enabling targeted solutions to ensure staff well-being.
A pediatric nurse is caring for multiple clients and reviewing each of their care plans. Which of the following client care interventions requires revising?
- A. Teach an adolescent who has an exacerbation of ulcerative colitis about a high-protein, low fiber diet.
- B. Administer a bronchodilator two times a day for child who has cystic fibrosis.
- C. Check the neurovascular status every 4 hr of a child who had a hip spica cast placed 6 hr ago.
- D. Maintain eye shields for a newborn receiving phototherapy for hyperbilirubinemia.
Correct Answer: B
Rationale: Bronchodilators for cystic fibrosis are needed more frequently, typically before each chest physiotherapy session, requiring revision of the care plan.
A nurse is teaching a group of assistive personnel about airborne precautions. Which of the following statements should the nurse make?
- A. Clients who have varicella should be placed in a positive pressure room.
- B. A client who has influenza requires airborne precautions.
- C. An N95 respirator mask is required when caring for a client who has the measles.
- D. Masks are not required when more than 3 ft from a client who requires airborne precautions.
Correct Answer: C
Rationale: An N95 respirator is required for measles, an airborne disease, to protect against droplet nuclei transmission.
A nurse on a medical surgical unit is caring for a group of clients with the assistance of a licensed practical nurse (LPN) and assistive personnel. Which of the following tasks should the nurse assign to the LPN?
- A. Providing postmortem care for a client who has just died
- B. Reinforcing dietary teaching with a client who has heart disease
- C. Accompanying a client who just had a wound debridement to physical therapy
- D. Obtaining a urine specimen from an older adult client
Correct Answer: D
Rationale: The correct answer is D, assigning the task of obtaining a urine specimen from an older adult client to the LPN. This task falls within the scope of practice for an LPN as it involves basic nursing skills and does not require critical thinking or assessment. LPNs are trained to perform routine procedures such as specimen collection under the supervision of a registered nurse. Providing postmortem care (A) requires emotional support and specialized knowledge beyond the LPN's scope. Reinforcing dietary teaching (B) and accompanying a client to physical therapy (C) involve critical thinking and assessment skills that are typically within the RN's scope. Therefore, D is the correct choice.