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A nurse is delegating tasks to an assistive personnel (AP) for a client with a pressure injury. Which of the following tasks is appropriate for the AP to perform?
- A. Assess the stage of the pressure injury.
- B. Reposition the client every 2 hours.
- C. Apply a prescribed wound dressing.
- D. Evaluate the client's skin integrity.
Correct Answer: B
Rationale: Repositioning the client every 2 hours is a routine task that helps prevent further skin breakdown and is within the AP's scope of practice. Assessment, dressing application, and evaluation require nursing judgment.
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A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first?
- A. An infant who has pertussis and is receiving oxygen via nasal cannula
- B. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions
- C. A school-age child who has diabetes mellitus and requires blood glucose monitoring
- D. A toddler who has both arms in casts and needs to be fed his breakfast
Correct Answer: A
Rationale: The correct answer is A. The nurse should assess the infant with pertussis receiving oxygen first because pertussis can cause severe respiratory distress. Assessing the infant's respiratory status is crucial as pertussis can lead to respiratory failure. Oxygen therapy is essential for maintaining adequate oxygenation levels. The nurse must monitor the infant's respiratory rate, effort, and oxygen saturation levels to ensure proper oxygenation. This assessment takes priority over the other clients' needs.
Choice B is incorrect because although the adolescent has sickle cell crisis, they are stable and ready for discharge instructions, which can be addressed after the critical assessment of the infant is completed.
Choice C is incorrect as monitoring blood glucose levels in a child with diabetes is important but does not take precedence over assessing a critically ill infant with pertussis.
Choice D is incorrect as feeding a toddler with both arms in casts can be challenging but does not pose an immediate threat to their health compared to the infant with pertussis requiring oxygen.
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A nurse on the pediatric unit is providing room assignments for children who are to be admitted to the unit. The nurse should plan to place a child who is postoperative from an appendectomy with which of the following clients?
- A. A child who is experiencing sickle cell crisis
- B. A child who has a head injury
- C. A child who has a new diagnosis of type 1 diabetes mellitus
- D. A child who has streptococcal pharyngitis
Correct Answer: C
Rationale: The correct answer is C. Placing the postoperative appendectomy child with a child who has a new diagnosis of type 1 diabetes mellitus is appropriate because both conditions typically require close monitoring but do not pose an immediate risk to each other. The child with appendectomy may need pain management and wound care, while the child with diabetes may need monitoring of blood glucose levels and insulin administration. Placing the postoperative child with a child experiencing sickle cell crisis (A) could be risky due to the potential for infection and stress on both children. Placing the child with a head injury (B) with a postoperative child could be dangerous as the child with a head injury may need a quiet environment and close monitoring for any neurological changes. Placing the child with streptococcal pharyngitis (D) with a postoperative child could increase the risk of infection for the postoperative child.
A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the client's provider, and completes an incident report, which of the following actions should the nurse take?
- A. Make a copy of the incident report for the provider.
- B. Submit the incident report to the risk manager.
- C. Place the incident report in the client's chart.
- D. Document in the chart that an incidence report has been filed.
Correct Answer: B
Rationale: The correct answer is B: Submit the incident report to the risk manager. This is the appropriate action because the risk manager is responsible for analyzing incidents to identify potential risks and implementing strategies to prevent them in the future. Providing the report to the risk manager allows for a comprehensive review and implementation of necessary measures.
Choice A is incorrect because making a copy of the incident report for the provider does not ensure that the incident is properly analyzed and addressed. Choice C is incorrect as placing the incident report in the client's chart may not reach the appropriate personnel for further action. Choice D is incorrect because simply documenting in the chart that a report has been filed does not facilitate a comprehensive review by the risk management team.
A nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts?
- A. False imprisonment
- B. Assault
- C. Battery
- D. Negligence
Correct Answer: C
Rationale: The correct answer is C: Battery. Battery is the intentional harmful or offensive touching of another person without consent. In this scenario, administering the antibiotic medication to a competent client after they have refused it constitutes a deliberate act of touching the client without their consent, which aligns with the definition of battery.
False imprisonment (A) involves restricting a person's freedom of movement unlawfully, which does not apply in this case. Assault (B) involves the threat of harmful or offensive contact, not the actual act itself. Negligence (D) is the failure to exercise proper care in a situation, which is not applicable here as the action was intentional.
A nurse is participating in a disaster drill for a chemical spill. Which of the following actions should the nurse take first when caring for exposed clients?
- A. Administer antidotes for the chemical agent.
- B. Decontaminate clients by removing contaminated clothing.
- C. Assess clients for respiratory distress.
- D. Document the number of affected clients.
Correct Answer: B
Rationale: Decontaminating clients by removing contaminated clothing is the first step to prevent further exposure and harm, aligning with disaster response protocols for chemical spills.