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A nurse is discussing emergency response with a newly licensed nurse. The nurse should identify which of the following as a triage officer during the time of a disaster?
- A. Nurses and other emergency medical personnel
- B. Responding law enforcement officers
- C. Members of the Federal Emergency Management Agency (FEMA)
- D. Representatives from the American Red Cross
Correct Answer: A
Rationale: The correct answer is A because nurses and other emergency medical personnel are trained to assess and prioritize patients based on their medical needs during a disaster. They have the expertise to quickly identify and categorize patients to ensure those with the most critical conditions receive immediate care. Responding law enforcement officers (B) focus on security and crowd control. Members of FEMA (C) are responsible for coordinating disaster response at a larger scale. Representatives from the American Red Cross (D) provide support services but do not typically serve as triage officers.
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A nurse is planning care for a client who has anorexia nervosa. The nurse should make which of the following client goals the priority?
- A. Identify changes within the family unit that promote the client's autonomy.
- B. Gain 2 pounds of weight per week.
- C. Make positive statements about improvements in body image.
- D. Feel in control of her behavior.
Correct Answer: B
Rationale: The correct answer is B: Gain 2 pounds of weight per week. In anorexia nervosa, the primary goal is to restore the client's weight to a healthy level to prevent serious health complications. Weight restoration is crucial in addressing the physical consequences of severe malnutrition and improving overall health. Gaining weight at a steady pace of 2 pounds per week is a realistic and safe goal.
Other choices are incorrect because:
A: Identifying changes within the family unit is important but not the priority compared to addressing the physical health concerns.
C: Making positive statements about improvements in body image is important for psychological well-being but does not address the immediate health risks associated with anorexia.
D: Feeling in control of behavior is a valid goal, but weight restoration takes precedence due to the critical nature of the client's physical health in anorexia nervosa.
A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?
- A. The client works in the hospital radiology department.
- B. The client discussed having prior thoughts of suicide.
- C. The client's blood pressure and pulse have been fluctuating throughout the day.
- D. The client's family members have been present most of the day.
Correct Answer: C
Rationale: The correct answer is C because fluctuating blood pressure and pulse indicate unstable vital signs requiring close monitoring and immediate intervention. The nurse giving report is indicating that the client's condition is dynamic and may require frequent assessments and interventions, which necessitates the oncoming nurse assuming total care. Choices A, B, and D do not directly imply the need for total care and could potentially be managed by assistive personnel.
A nurse is planning to delegate a task to an assistive personnel (AP). Which of the following actions should the nurse plan to take?
- A. Determine the social skills of the AP.
- B. Assess the AP's ability to follow the client's teaching plan.
- C. Provide a clear description of the task to the AP.
- D. Evaluate the ability of the AP to work with peers.
Correct Answer: C
Rationale: The correct answer is C: Provide a clear description of the task to the AP. This is essential in delegation to ensure the AP understands what is expected. Determining social skills (A) and evaluating ability to work with peers (D) are not directly related to task delegation. Assessing ability to follow a teaching plan (B) is important but not the primary focus in task delegation.
A nurse is caring for a client who is postoperative and has a chest tube. The nurse notes that the chest tube is disconnected from the drainage system. Which of the following actions should the nurse take first?
- A. Reconnect the chest tube to the drainage system.
- B. Clamp the chest tube near the insertion site.
- C. Notify the provider of the disconnection.
- D. Place the end of the chest tube in sterile water.
Correct Answer: D
Rationale: Placing the end of the chest tube in sterile water prevents air from entering the pleural space, which could cause a pneumothorax, making it the priority action.
A nurse is delegating client care assignments for the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
- A. Teach a client about low-sodium foods.
- B. Measure and record intake and output for a client.
- C. Perform wound irrigation for a client.
- D. Evaluate pain relief for a client following the administration of a pain medication.
Correct Answer: B
Rationale: The correct answer is B: Measure and record intake and output for a client. This task can be safely delegated to an assistive personnel (AP) as it is a non-invasive and routine task that does not involve critical thinking or interpretation. APs are trained to perform basic tasks like measuring and recording intake and output accurately under the supervision of a nurse. Other choices are incorrect because: A involves providing client education which requires critical thinking and assessment skills, C involves a procedure that requires specific training and skill, and D involves evaluating the effectiveness of pain relief which requires nursing judgment and assessment skills.