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A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
- A. Initiate seclusion protocol.
- B. Use a face shield with a mask when providing care to the client
- C. Tell the client, 'You seem to be very upset.'
- D. Engage the panic alarm
Correct Answer: C
Rationale: The correct answer is C. When a client is aggravated, pacing, and speaking loudly, it is important to acknowledge their feelings. By telling the client, "You seem to be very upset," the nurse shows empathy and validates the client's emotions. This can help de-escalate the situation by demonstrating understanding and openness to communication. It also allows the nurse to assess the client's needs and concerns effectively.
Choice A is incorrect as initiating seclusion protocol should only be considered for extreme cases where the client poses a danger to themselves or others. Choice B is unnecessary in this situation as it does not address the client's emotional state. Choice D, engaging the panic alarm, is premature and could escalate the situation further.
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A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test?
- A. An induration measuring 10 mm
- B. An induration measuring 5 mm
- C. A reddened area measuring 10 mm
- D. A reddened area measuring 5 mm
Correct Answer: A
Rationale: The correct answer is A: An induration measuring 10 mm. An induration of 10 mm or greater is considered a positive result for a tuberculin skin test in individuals who are at higher risk for tuberculosis. This indicates exposure to the tuberculosis bacteria and an immune response. Choices B, C, and D are incorrect because the presence of redness or a smaller induration size does not meet the criteria for a positive test result. Redness alone does not signify a positive result, and a smaller induration size is not indicative of a positive test. It is important to interpret tuberculin skin tests accurately to guide further testing and treatment decisions.
A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications?
- A. Acetylcysteine
- B. Protamine
- C. Naloxone
- D. Flumazenil
Correct Answer: C
Rationale: The correct answer is C: Naloxone. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, such as respiratory depression. In this case, the client's respiratory rate of 10/min indicates opioid overdose due to hydromorphone. Naloxone administration can help reverse the respiratory depression and restore normal breathing.
Choice A: Acetylcysteine is used for acetaminophen overdose, not opioid overdose.
Choice B: Protamine is used to reverse the effects of heparin, not opioids.
Choice D: Flumazenil is a benzodiazepine antagonist, not an opioid antagonist.
Therefore, the most appropriate choice in this scenario is Naloxone to address the opioid overdose and respiratory depression.
A nurse is caring for a client who is receiving brachytherapy for endometrial cancer. Which of the following actions should the nurse take?
- A. Discard the radioactive source in the client's trash can.
- B. Place the client's soiled bed linens in a biohazard bag outside the client's room
- C. Wear an isolation gown when caring for the client
- D. Keep visitors at least 6 feet (1.8 m) away from the client.
Correct Answer: D
Rationale: The correct answer is D: Keep visitors at least 6 feet (1.8 m) away from the client. This is important in brachytherapy as the client is emitting radiation. By keeping visitors at a safe distance, the nurse ensures their safety from radiation exposure. A: Discarding the radioactive source in the trash can is incorrect as it poses a risk to others. B: Placing soiled linens in a biohazard bag is not directly related to radiation safety. C: Wearing an isolation gown does not provide sufficient protection against radiation. Therefore, it is important for the nurse to maintain distance to prevent radiation exposure to visitors.
A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following hip replacement surgery. Which of the following instructions should the nurse include?
- A. Encourage the client to avoid wearing shoes at home.
- B. Place a throw rug over electrical cords
- C. Mark the edges of the doorway to the house with tape.
- D. Ensure that area rugs have rubber backs.
Correct Answer: D
Rationale: The correct answer is D: Ensure that area rugs have rubber backs. This instruction helps prevent slipping and falling, which is crucial for a postoperative hip replacement patient. Rubber-backed rugs provide stability and reduce the risk of accidents. Option A is incorrect as wearing shoes at home can increase the risk of falls. Option B is incorrect as placing a throw rug over electrical cords can lead to tripping hazards. Option C is incorrect as marking doorways with tape does not address home safety concerns for a postoperative patient.
A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively?
- A. Delegate tasks to the AP
- B. Determine goals of the day.
- C. Develop an hourly time frame for tasks
- D. Schedule daily activities
Correct Answer: B
Rationale: The correct answer is B: Determine goals of the day. This is the first step to managing time effectively as it helps prioritize tasks and establish a clear direction for care delivery. By setting goals, the nurse can focus on important tasks, delegate appropriately, and allocate time efficiently.
A: Delegating tasks to the AP can come after determining goals to ensure tasks are aligned with priorities.
C: Developing an hourly time frame for tasks can be done once goals are established to create a detailed schedule.
D: Scheduling daily activities is important but should be based on the goals set for the day.
In summary, determining goals of the day is the initial step in time management as it provides a framework for prioritizing tasks and organizing activities efficiently.