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A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse prioritize?
- A. Place the client in a high-Fowler's position.
- B. Insert a tongue depressor to prevent tongue biting.
- C. Protect the client from injury by clearing the area.
- D. Administer a prescribed anticonvulsant immediately.
Correct Answer: C
Rationale: Protecting the client from injury by clearing the area is the priority to ensure safety during a seizure. Positioning, tongue depressors, and medication administration are secondary or contraindicated.
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A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first?
- A. A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min
- B. An adolescent who has sickle cell disease, reports pain as 7 on a scale of 0 to 10, and requests pain medication
- C. A toddler who has otitis media, a temperature of 39.2 C (102.6° F), and purulent ear discharge
- D. A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough
Correct Answer: D
Rationale: The correct answer is D. Acute epiglottitis is a medical emergency due to potential airway compromise. The child's drooling and absence of cough indicate a severe obstruction that can rapidly progress to complete airway closure. Immediate intervention is crucial to prevent respiratory distress or arrest. Choices A, B, and C have less urgent conditions that can be managed after ensuring the child with epiglottitis receives prompt care. Choice A, although having asthma, is stable with adequate oxygenation. Choice B, although in pain, can wait briefly for pain medication. Choice C, although having otitis media, does not present immediate life-threatening risk compared to epiglottitis.
A nurse is supervising a newly licensed nurse who is caring for a client on a behavioral health unit. Complete the following sentence by using the list of options.
- A. provide continuous monitoring of this client
- B. assess for readiness for release from seclusion
- C. clearly document reason for seclusion then obtain provider prescription for seclusion or restraints
- D. provide means for hygiene and elimination
- E. discuss reason for seclusion with client
- F. offer food and fluids
Correct Answer: A,C
Rationale: The correct answers are A and C. A is important to ensure the safety and well-being of the client, especially in a behavioral health unit where close monitoring is crucial. C is necessary to ensure proper documentation and adherence to protocols when seclusion or restraints are used. B is incorrect as assessing readiness for release from seclusion should only be done by a qualified provider. D is important but not as urgent as continuous monitoring. E is not appropriate as discussing the reason for seclusion with the client may not be beneficial during an acute episode. F is important but providing food and fluids should not be the priority over continuous monitoring and proper documentation.
A nurse is leading a debriefing session after a critical incident on the unit. Which of the following actions should the nurse take to support the team?
- A. Focus on assigning blame for the incident.
- B. Encourage staff to share their feelings and experiences.
- C. Criticize staff for errors made during the incident.
- D. Limit the discussion to procedural changes only.
Correct Answer: B
Rationale: Encouraging staff to share their feelings and experiences promotes emotional support and team cohesion, helping staff process the incident and identify areas for improvement.
A nurse is preparing to administer a prescribed medication to a client. Which of the following actions should the nurse plan to take to demonstrate client advocacy?
- A. Insist the client take prescribed medications.
- B. Inform the client that the medication is the same as taken at home.
- C. Tell the client that refusal of the medication is considered noncompliance.
- D. Encourage the client to verbalize questions.
Correct Answer: D
Rationale: The correct answer is D: Encourage the client to verbalize questions. This demonstrates client advocacy as it empowers the client to actively participate in their care, promotes informed decision-making, and ensures understanding of the medication. This approach respects the client's autonomy and right to make informed choices. It also allows the nurse to address any concerns or misconceptions the client may have, leading to better adherence to the treatment plan.
Incorrect choices:
A: Insisting the client take prescribed medications goes against the principles of client autonomy and informed consent.
B: Simply informing the client about the medication without addressing their questions or concerns does not actively involve the client in their care.
C: Labeling the client's refusal as noncompliance can be seen as judgmental and does not encourage open communication or shared decision-making.
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.