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A nurse is conducting triage of clients transported from a mass casualty incident (MCI). A client arrives saturated with an unknown substance and medical transport reports feeling dizzy. The nurse should prioritize which actions? SELECT ALL THAT APPLY
- A. Assign the client to a private room
- B. Remove client and transport crew from the Emergency department
- C. Contact decontamination team
- D. Call the scene to identify the chemical
- E. Immediately remove the saturated clothing from the client
Correct Answer: B,C,E
Rationale: Correct Answer: B, C, E
Rationale:
1. Option B - Removing the client and transport crew from the Emergency department is crucial to prevent potential contamination of others and ensure safety.
2. Option C - Contacting the decontamination team is essential to properly manage and decontaminate the client and the area.
3. Option E - Removing the saturated clothing from the client immediately helps eliminate further exposure and contamination risks.
Incorrect Answers:
A: Assign the client to a private room - This is not the priority as immediate decontamination and safety measures are needed.
D: Call the scene to identify the chemical - Identifying the substance is important but not the priority when the client's safety is at risk.
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A nurse is caring for a client receiving rehabilitation for paralysis following a spinal cord injury and diagnosed with reflex incontinence. Which of the following is the highest priority intervention the nurse should include in the plan of care?
- A. Limited fluid intake to prevent incontinence
- B. Administration of antispasmodic medication
- C. Kegel exercises to strengthen the pelvic floor
- D. Regular perineal care to prevent skin breakdown
Correct Answer: D
Rationale: The correct answer is D: Regular perineal care to prevent skin breakdown. This is the highest priority intervention because reflex incontinence can lead to constant urine leakage, increasing the risk of skin breakdown. Regular perineal care helps maintain skin integrity, preventing complications like pressure ulcers. Limited fluid intake (A) is not appropriate as it can lead to dehydration. Antispasmodic medication (B) may help manage muscle spasms but does not address skin breakdown. Kegel exercises (C) are beneficial for stress incontinence, not reflex incontinence.
A nurse is educating nursing students on the importance of client-centered community-based care. The nurse understands that which of the following principles is most essential to client-centered, community-based care in nursing?
- A. Encouraging clients to make decisions without considering their cultural or social background
- B. Ensuring that care plans are tailored to the individual needs and preferences of clients within their community
- C. Focusing primarily on the medical treatment of diseases within a hospital setting
- D. Prioritizing the efficiency of healthcare delivery over patient satisfaction and outcomes
Correct Answer: B
Rationale: Correct Answer: B - Ensuring that care plans are tailored to the individual needs and preferences of clients within their community.
Rationale:
1. Client-centered care emphasizes individuality: By tailoring care plans to individual needs and preferences, nurses show respect for each client's unique circumstances.
2. Community-based care focuses on local resources: By considering the community context, nurses can incorporate resources and support systems specific to the client's environment.
3. Personalized care enhances outcomes: Addressing individual needs leads to better engagement, adherence, and overall health outcomes for clients.
4. Promotes empowerment and autonomy: Involving clients in care planning based on their preferences fosters autonomy and empowers them to actively participate in their own health management.
Summary:
- Choice A neglects the importance of cultural and social backgrounds in decision-making, which are key factors in providing client-centered care.
- Choice C focuses on a hospital setting, not community-based care.
- Choice D prioritizes efficiency over patient satisfaction,
A nurse is delegating tasks to the assistive personnel (AP). The nurse should direct the AP to complete which of the following tasks first?
- A. Assisting a client with a bed bath who has a history of falls
- B. Providing a snack to a diabetic client who is feeling lightheaded
- C. Feeding a client who has bilateral casts due to upper arm fractures
- D. Ambulating a postoperative client for the first time
Correct Answer: B
Rationale: The correct answer is B because providing a snack to a diabetic client who is feeling lightheaded addresses an immediate physiological need. Hypoglycemia can lead to serious complications and needs to be addressed promptly to prevent harm. Choices A, C, and D involve important tasks but do not address an urgent physiological need like hypoglycemia. Assisting a client with a bed bath, feeding a client with bilateral casts, or ambulating a postoperative client can be prioritized based on the client's condition and safety but do not take precedence over addressing a potential medical emergency like hypoglycemia.
The school nurse identifies 12 students with confirmed cases of influenza A. The families of the children are advised to keep the children home for a minimum of 5 to 7 days. Which of the following is an appropriate action by the nurse?
- A. Closing the school for 6 weeks
- B. Education regarding respiratory and hand hygiene
- C. Discipline in the school setting for improper handwashing
- D. Running a mandatory flu clinic
Correct Answer: B
Rationale: Correct Answer: B - Education regarding respiratory and hand hygiene
Rationale:
1. Education on respiratory and hand hygiene is crucial in preventing the spread of influenza.
2. By educating families and students, the nurse empowers them to take proactive measures.
3. Closing the school for 6 weeks is excessive and disrupts education.
4. Discipline for improper handwashing is reactive and may not address the root cause effectively.
5. Running a mandatory flu clinic may help, but education on hygiene is a preventive measure.
The nurse is caring for a client with multiple sclerosis. What action does the nurse implement to increase venous return, prevent stiffness, and maintain muscle strength and endurance?
- A. Encourage the client to use ice therapy to alleviate muscle stiffness
- B. Administer interferon
- C. Administer corticosteroids
- D. Encourage the client to perform gentle stretching exercises daily
Correct Answer: D
Rationale: The correct answer is D: Encourage the client to perform gentle stretching exercises daily. Stretching exercises help increase venous return by improving circulation, prevent stiffness by maintaining joint flexibility, and maintain muscle strength and endurance by promoting muscle health. Ice therapy (choice A) may temporarily alleviate stiffness but does not address venous return or muscle strength. Administering interferon (choice B) and corticosteroids (choice C) are medications used for managing symptoms but do not directly address the goals of increasing venous return or maintaining muscle strength.