Nokea
A nurse in an emergency department receives report from an emergency responder who states a client is being transported following exposure to a 'dirty bomb'. The nurse should prepare to care for a client that has been exposed to which of the following types of agents?
- A. Radiologic
- B. Anthrax
- C. Chemical
- D. Sarin
Correct Answer: A
Rationale: The correct answer is A: Radiologic. A 'dirty bomb' combines conventional explosives with radioactive material, leading to radiologic exposure. The emergency responder's report of a 'dirty bomb' indicates potential radiation exposure. Choice B, Anthrax, is incorrect as it is a biological agent. Choice C, Chemical, is incorrect as it refers to exposure to toxic chemicals. Choice D, Sarin, is incorrect as it is a nerve agent. In summary, the nurse should prepare for radiologic exposure due to the 'dirty bomb' incident.
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A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?
- A. Call the provider for a stat DNR order.
- B. Call the emergency response team.
- C. Seek immediate help from the risk manager.
- D. Respect the family's wishes and do nothing.
Correct Answer: B
Rationale: The correct answer is B: Call the emergency response team. In this scenario, the nurse encounters a pulseless client with pending DNR status. Calling the emergency response team is crucial as they are trained to assess the situation and provide appropriate interventions. It ensures that the client receives immediate assistance in a potentially life-threatening situation. Seeking a stat DNR order (choice A) may waste valuable time and delay necessary actions. Involving the risk manager (choice C) is not the priority when a client is pulseless. Simply respecting the family's wishes and doing nothing (choice D) goes against the nurse's duty to provide timely and appropriate care.
An assistive personnel (AP) comes to work with a new set of artificial nails. The nurse takes the AP to a private location to discuss the issue. Which of the following statements by the nurse is appropriate?
- A. I want you to review the facility's policy on personal attire before you begin the shift.
- B. There is a higher risk of infection for our clients associated with artificial nails.
- C. Why would you wear artificial nails to work when you know it's against the rules?
- D. You should know that artificial nails have a very unprofessional appearance.
Correct Answer: B
Rationale: The correct answer is B: There is a higher risk of infection for our clients associated with artificial nails. This statement is appropriate because it directly addresses the potential harm that the AP's artificial nails could pose to clients. Artificial nails can harbor bacteria and increase the risk of transmitting infections in a healthcare setting. It focuses on the importance of infection control and patient safety.
Other choices are incorrect:
A: While reviewing facility policy is important, it does not directly address the issue of infection risk.
C: This statement is accusatory and does not promote a constructive dialogue about infection control.
D: Commenting on appearance is not relevant to the infection risk associated with artificial nails.
A charge nurse is reviewing documentation in the medical record from a newly licensed nurse. Click to highlight the findings that indicate this nurse requires additional education.
- A. The client is inappropriate and is a huge fall risk
- B. The provider has denied this RN's requests for physical or chemical restraints
- C. They appear 'medically stable
- D. the partner is at bedside and said that their spouse is always complaining or arguing
- E. Morphine 10mg IV given orally
- F. The client has a history of major depressive disorder and alcohol use disorder
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D. A indicates the nurse's lack of understanding of patient safety by not recognizing the fall risk. B suggests a lack of knowledge on restraint alternatives. C shows an inadequate assessment of the patient's overall condition. D reflects poor communication skills and lack of understanding of family dynamics. Choices E and F are not necessarily indicative of a need for additional education based on the information provided.
A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.)
- A. Apply an ambulation alarm to the client's leg.
- B. Obtain a prescription to restrain the client PRN.
- C. Instruct the client in the use of the call light.
- D. Raise all side rails on the client's bed.
- E. Check on the client hourly.
Correct Answer: A,C,E
Rationale: The correct actions are A, C, and E. Applying an ambulation alarm to the client's leg helps prevent falls by alerting staff when the client attempts to get out of bed. Instructing the client in the use of the call light promotes safety by enabling them to request assistance when needed. Checking on the client hourly allows for monitoring and timely intervention if the client is at risk of falling. Choice B, obtaining a prescription to restrain the client PRN, is incorrect as physical restraints can have adverse effects and should be used as a last resort. Choice D, raising all side rails on the client's bed, is incorrect because it may lead to feelings of confinement and is not recommended as a fall prevention strategy.
A nurse is caring for a client who is confused and uncooperative. The client hit the nurse when she attempted to give him his medication. The nurse asks the charge nurse if she can restrain the client. The charge nurse should tell the nurse this action is a violation of the client's rights and is an example of which of the following?
- A. Defamation of character
- B. Slander
- C. False imprisonment
- D. Invasion of privacy
Correct Answer: C
Rationale: Correct Answer: C. False imprisonment
Rationale:
1. False imprisonment is the intentional restriction of a person's freedom of movement without justification.
2. Restraining the client against their will without a valid reason is a violation of their rights.
3. The client has the right to refuse treatment, and restraining them would be considered false imprisonment.
4. Defamation of character (A) and slander (B) involve damaging one's reputation through false statements.
5. Invasion of privacy (D) pertains to intrusion into a person's private affairs, not physical restraint.