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A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take?
- A. Reinforce discharge teaching to clients.
- B. Focus on providing care that prevents life-threatening emergencies.
- C. Stock additional unit supplies.
- D. Instruct the assistive personnel (AP) to focus on clients' ADLs.
Correct Answer: B
Rationale: Correct Answer: B - Focus on providing care that prevents life-threatening emergencies.
Rationale: During a disaster, the nurse's priority is to ensure the safety and well-being of clients by focusing on providing care that prevents life-threatening emergencies. By prioritizing care to prevent life-threatening situations, the nurse can help maintain the stability and health of clients during the crisis. This action aligns with disaster protocols and ensures that resources are utilized effectively to address the most critical needs first.
Incorrect Choices:
A: Reinforcing discharge teaching is not a priority during a disaster when immediate life-saving interventions are needed.
C: Stocking additional supplies may be important, but it is not the immediate priority when working with limited staff during a severe storm.
D: Instructing assistive personnel to focus on clients' ADLs may not address the urgency of preventing life-threatening emergencies during a disaster.
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A nurse is on the hospital quality and performance Improvement committee. The committee is reviewing compliance with prevention measures related to posterior cervical surgical site infections over the first 3 quarters of the year. Which measures should the nurse recognize that indicate the need for improvement compared to benchmarks? Select all that apply.
- A. Glucose control
- B. Intraoperative vancomycin
- C. Post operative normothermia
- D. Perioperative antibiotics
- E. Smoking cessation
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. Glucose control, perioperative antibiotics, and smoking cessation are important prevention measures related to posterior cervical surgical site infections. Glucose control is crucial as hyperglycemia can impair immune function, leading to increased infection risk. Perioperative antibiotics help prevent surgical site infections by reducing bacterial load. Smoking cessation is vital as smoking impairs wound healing and increases infection risk. Intraoperative vancomycin (B) is not typically a prevention measure for surgical site infections in posterior cervical surgeries. Postoperative normothermia (C) is important for general patient care but is not specifically related to preventing surgical site infections in this context.
A charge nurse is planning to conduct a performance appraisal of a staff member on her unit. Which of the following actions should the nurse take?
- A. Inform the staff member of her appraisal time for that day prior to change-of-shift report.
- B. Schedule the appraisal interview as early in the shift as possible.
- C. Provide the staff member with a copy of the appraisal form in advance.
- D. Provide a chair directly across the desk for the staff member to sit in.
Correct Answer: C
Rationale: The correct answer is C: Provide the staff member with a copy of the appraisal form in advance. This action is essential as it allows the staff member to review the form, prepare their thoughts, and gather any necessary documentation or evidence to support their performance. By providing the form in advance, the staff member can actively participate in the appraisal process and engage in a meaningful discussion during the appraisal interview. This approach promotes transparency, fairness, and constructive feedback.
Other choices are incorrect:
A: Informing the staff member of the appraisal time prior to change-of-shift report may not give them adequate time to prepare for the appraisal.
B: Scheduling the appraisal interview as early in the shift as possible may not allow the staff member enough time to mentally prepare for the appraisal.
D: Providing a chair directly across the desk for the staff member to sit in is a physical setup and does not address the preparation aspect of the performance appraisal.
An assistive personnel (AP) reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP?
- A. Palpate for possible bladder distention.
- B. Observe the incision site.
- C. Change the abdominal dressing.
- D. Obtain vital signs.
Correct Answer: D
Rationale: The correct answer is D: Obtain vital signs. Vital signs are essential to assess the client's overall condition and determine the urgency of the situation. The AP can measure and report the vital signs to the nurse promptly. Palpating for bladder distention (choice A) requires a higher level of assessment and may indicate a complication postoperatively. Observing the incision site (choice B) involves assessing for signs of infection or other complications, which should be done by a nurse. Changing the abdominal dressing (choice C) requires sterile technique and assessment skills beyond the AP's scope. Therefore, delegating these tasks to the AP could delay necessary interventions.
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 assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first?
- A. A client who has pneumonia and has an axillary temperature of 38° C (101° F)
- B. A client who has diarrhea and requests clear liquids for breakfast
- C. A client who has a cast on the left leg and reports numbness and paresthesia
- D. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150
Correct Answer: C
Rationale: The correct answer is C because numbness and paresthesia in a client with a cast can indicate compartment syndrome, a medical emergency requiring immediate attention to prevent tissue damage or loss of limb. This condition can lead to permanent disability if not addressed promptly. Clients with pneumonia (choice A) and elevated temperature can be managed with antipyretics and antibiotics, while a client with diarrhea (choice B) requesting clear liquids can be managed with dietary adjustments. A client with type 1 diabetes and a blood glucose level of 150 (choice D) may require insulin adjustment but is not as urgent as addressing potential compartment syndrome.