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A nurse working on a medical-surgical unit is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients?
- A. A client who has orthostatic hypotension and is receiving IV fluids
- B. A client who is receiving heparin and has an aPTT of 34 seconds
- C. A client who has Type 1 diabetes and uses an insulin pump
- D. A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL
Correct Answer: D
Rationale: Pressure ulcer risk and nutritional concerns require interdisciplinary collaboration (e.g., dietitian, physical therapist) for comprehensive care.
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A nurse is providing an in-service about actions to take during a fire on the unit. Which of the following instructions should the nurse include?
- A. Place dry towels at the base of doors.
- B. Move client care equipment into the hallway.
- C. Close the windows in client rooms.
- D. Use the fire extinguisher by aiming at the top of the flames.
Correct Answer: C
Rationale: The correct answer is C: Close the windows in client rooms. Closing windows can help prevent the spread of fire by limiting oxygen supply. This action can help contain the fire within the unit and prevent it from escalating. Placing dry towels at door bases (choice A) can be dangerous as they can catch fire. Moving client care equipment into the hallway (choice B) can obstruct evacuation routes. Using a fire extinguisher by aiming at the top of flames (choice D) is incorrect as the base of the fire should be targeted to extinguish it effectively.
A nurse in the emergency department admits a client who has been exposed to cutaneous anthrax. Which of the following actions should the nurse take?
- A. Plan to administer an antiviral medication to the client.
- B. Place a surgical mask on the client during transfer to the unit.
- C. Prepare to administer antibiotics to the client.
- D. Wear an N95 respirator mask while caring for the client.
Correct Answer: C
Rationale: The correct answer is C: Prepare to administer antibiotics to the client. Cutaneous anthrax is caused by Bacillus anthracis bacteria, which can be effectively treated with antibiotics such as ciprofloxacin or doxycycline. Administering antibiotics promptly can prevent the progression of the infection.
A: Antiviral medications are used to treat viral infections, not bacterial infections like anthrax.
B: Placing a surgical mask on the client is not necessary for cutaneous anthrax, as it is not transmitted through respiratory droplets.
D: While wearing an N95 respirator mask is important for respiratory precautions in certain infectious diseases, it is not specifically required for cutaneous anthrax transmission.
In summary, administering antibiotics is the most appropriate action to treat cutaneous anthrax, while the other options are not relevant for this specific situation.
A nurse is assessing a client who had a stroke 2 days ago. Which of the following findings should the nurse identify as a need for a referral to speech-language pathology?
- A. Diminished hand-to-mouth coordination
- B. Impaired voluntary cough
- C. Unilateral ptosis
- D. Altered level of consciousness
Correct Answer: B
Rationale: The correct answer is B: Impaired voluntary cough. Impaired voluntary cough in a client who had a stroke can indicate dysphagia, which is a common complication post-stroke. Referral to speech-language pathology is essential for assessing and managing dysphagia to prevent aspiration pneumonia and malnutrition. Diminished hand-to-mouth coordination (A) may indicate motor deficits but does not directly relate to speech and swallowing. Unilateral ptosis (C) is a drooping eyelid and is not typically a direct concern for speech-language pathology. Altered level of consciousness (D) may indicate neurological issues but does not specifically warrant a referral to speech-language pathology.
A facility provides annual staff education regarding ethical practice. A charge nurse recognizes a need for further education when which of the following behaviors is observed?
- A. A nurse informs a confused client who wants to go home that he is going to stay at the facility until he is better.
- B. A nurse gives prescribed opioids to a client who has a terminal illness and respirations of 8/min.
- C. A nurse explains to a client's family that a DNR order includes withholding comfort measures.
- D. A nurse refuses to actively participate during an elective abortion procedure scheduled for her client.
Correct Answer: C
Rationale: The correct answer is C. This is the only behavior that goes against ethical practice in this scenario. The charge nurse should recognize the need for further education when a nurse incorrectly explains that a DNR order includes withholding comfort measures, as this is inaccurate information. Justification for other choices: A is incorrect because it shows compassionate care. B is incorrect because it demonstrates appropriate pain management for a terminally ill client. D is incorrect because nurses have the right to refuse participation in procedures that go against their beliefs.
A nurse enters a client's room and notices a small fire in the bathroom trash can. The nurse removes the client from the room. Which of the following actions should the nurse take next?
- A. Activate the fire alarm.
- B. Close the fire doors and the doors to the clients' rooms.
- C. Remove all clients from the unit.
- D. Extinguish the fire.
Correct Answer: A
Rationale: The correct answer is A: Activate the fire alarm. This is the most critical step as it alerts others in the facility to the fire, ensuring swift evacuation and response from the fire department. Closing fire doors (choice B) and removing all clients from the unit (choice C) are important steps but should be done after the fire alarm is activated. Attempting to extinguish the fire (choice D) before ensuring everyone's safety is not recommended as it can put the nurse and clients at risk.