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A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately?
- A. A middle adult male who is diaphoretic and reports epigastric pain
- B. A toddler who has a laceration on his forehead and is screaming
- C. An adolescent female client who is belligerent and has slurred speech
- D. A young adult with a painful sunburn of his face and arms
Correct Answer: A
Rationale: The correct answer is A. The nurse should have the provider care for the middle adult male who is diaphoretic and reports epigastric pain immediately. Diaphoresis and epigastric pain can be signs of a heart attack or other serious cardiac issue, requiring urgent medical attention to prevent complications. The other choices do not present an immediate life-threatening situation. The toddler with a laceration can be addressed after stabilizing the critical client. The belligerent adolescent may need behavioral intervention but does not require immediate medical attention. The young adult with sunburn, while painful, is not a life-threatening condition that requires immediate provider care.
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A nurse is preparing to bathe a client. Which of the following actions should the nurse plan to take?
- A. Fill the bath basin with tap water that is 39° C (102.2° F).
- B. Pull the curtain around the client's bed.
- C. Wash the client's arms and hands first.
- D. Use a washcloth to wipe the client's eyes from the outer canthus to the inner canthus.
Correct Answer: B
Rationale: The correct answer is B: Pull the curtain around the client's bed. This action ensures the client's privacy and maintains their dignity during the bathing process. By creating a physical barrier with the curtain, the nurse respects the client's autonomy and promotes a comfortable environment.
Choice A is incorrect because the water temperature specified may not be suitable for the client, as it is too hot. Choice C is incorrect as washing the arms and hands first may not be the most efficient or logical sequence for a full-body bath. Choice D is incorrect because wiping the client's eyes with a washcloth in that direction can introduce contaminants into the eyes.
A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent?
- A. The client
- B. The client's son, who has a durable power of attorney
- C. The client's partner
- D. The client's daughter, who is the primary caregiver
Correct Answer: A
Rationale: The correct answer is A: The client. Informed consent must be given by the client themselves, as they are alert, oriented, and have advance directives. This ensures that the client fully understands the procedure, risks, benefits, and alternatives before giving consent. The client's autonomy and right to make decisions about their own healthcare are paramount. The other choices are incorrect because only the client themselves can provide informed consent in this scenario. The son with durable power of attorney may make decisions when the client is unable to, but since the client is alert and oriented, they should sign the consent. The partner and daughter do not have the authority to provide informed consent on behalf of the client.
A nurse has assigned client care activities to an assistive personnel (AP). Which of the following statements by the AP Indicates a need for assistance in establishing priorities?
- A. I have my assignment and will start with room 1, then work my way to room 10.
- B. After breakfast, I will pack the belongings of clients who will be discharged this morning.
- C. I will start by providing partial baths before breakfast.
- D. I will give this client his meal tray first, as he is going early to physical therapy.
Correct Answer: A
Rationale: The correct answer is A because the AP's statement lacks prioritization based on client needs or acuity. Starting with room 1 and working way to room 10 may not address urgent needs. Choice B demonstrates an understanding of the timely task of packing for discharged clients. Choice C indicates a proactive approach to hygiene needs. Choice D highlights prioritizing based on a client's scheduled activity. Overall, choice A lacks a clear understanding of prioritization in client care, making it the correct answer.
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 preparing a report for the quality improvement committee about medication errors. Which of the following data should the nurse include to evaluate the effectiveness of current interventions?
- A. The number of staff trained on medication safety protocols.
- B. The cost of implementing new medication scanners.
- C. The percentage of medication errors before and after interventions.
- D. The satisfaction scores from staff using new medication systems.
Correct Answer: C
Rationale: The correct answer is C, the percentage of medication errors before and after interventions. This data is crucial for evaluating the effectiveness of current interventions because it directly measures the impact of the interventions on reducing medication errors. By comparing the percentage of errors before and after the interventions, the nurse can determine if the interventions have been successful in improving medication safety.
Choice A is incorrect because while staff training is important, it does not directly measure the effectiveness of interventions on reducing errors.
Choice B is incorrect as the cost of implementing new scanners is not a direct indicator of effectiveness in reducing medication errors.
Choice D is incorrect as staff satisfaction scores do not necessarily reflect the actual impact on medication error reduction.
In summary, monitoring the percentage of medication errors before and after interventions provides a clear, objective measure of the effectiveness of current interventions in improving medication safety.