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During a disaster triage situation with limited ICU beds and resources, the nurse must recommend which clients should receive priority for ICU admission. Which of the following clients should be prioritized? Select all that apply.
- A. A client with a flail chest and respiratory distress requiring intubation
- B. A client with a Glasgow Coma Scale (GCS) score of 3 and fixed pupils
- C. A client with septic shock responding to vasopressors and fluids
- D. A client with extensive full-thickness burns over 85% of the total body surface area
- E. A client with an open leg fracture and stable vital signs
- F. A client with a traumatic brain injury and signs of increasing intracranial pressure
Correct Answer: A, C, F
Rationale: Clients with flail chest requiring intubation (A), septic shock responding to treatment (C), and traumatic brain injury with increasing intracranial pressure (F) have salvageable conditions needing ICU care. GCS of 3 with fixed pupils (B) indicates poor prognosis, extensive burns (D) have low survival likelihood, and stable leg fracture (E) is non-critical.
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The nurse is participating in a committee with the objective of promoting healthcare justice in the community. Which of the following recommendations should the nurse make to achieve the goal?
- A. establishing interdisciplinary collaboration between nursing and nutritional services
- B. providing more confidential waste containers at local drug stores
- C. offering free telehealth offerings in underserved areas of the community
- D. offering inpatient clients the ability to select their meal times
Correct Answer: C
Rationale: Free telehealth in underserved areas (C) promotes healthcare justice by improving access for disadvantaged populations. Interdisciplinary collaboration (A), waste containers (B), and meal time selection (D) are beneficial but less directly address equitable access.
The nurse is caring for assigned clients. The nurse should initially
- A. evaluate a client’s Mantoux test for tuberculosis tuberculin skin (TB) test for reactivity 48 hours after it has been administered.
- B. assess a client with atrial fibrillation who has an irregular pulse (P) of 90 beats/minute.
- C. apply the catheter prescribed medication to the lumbar back region of a client with chronic pain.
- D. administer the prescribed antibiotic scheduled for a client with peritonitis.
Correct Answer: D
Rationale: Administering antibiotics for peritonitis (C) is the priority to treat life-threatening intra-abdominal infection. TB test evaluation (D), AF pulse assessment (B), and lidocaine patch application (A) are less urgent, as they address stable or chronic conditions.
A hospital is initiating its emergency disaster plan following a mass casualty incident. Which client should the nurse recommend for discharge in preparation for the incoming clients?
- A. A client with type 1 diabetes admitted for new-onset diabetic ketoacidosis and is receiving intravenous insulin
- B. A client with atrial fibrillation admitted 2 days ago, now on oral anticoagulants and in normal sinus rhythm
- C. A client admitted with community-acquired pneumonia requiring oxygen at 3 L/min via nasal cannula
- D. A client admitted with a tibial fracture 6 hours ago, who is post-operative with a cast and stable vital signs
Correct Answer: B
Rationale: The client with atrial fibrillation, now stable on oral anticoagulants (B), is the most suitable for discharge to free beds. Diabetic ketoacidosis (A), pneumonia with oxygen (C), and recent post-operative fracture (D) require ongoing hospital care.
The nurse has been tasked with developing and leading a multidisciplinary team to improve client safety and has been informed that previous group formations were unsuccessful due to poor team dynamics. When developing and leading this committee, it is essential that the nurse initially
- A. develop a code of conduct for the team.
- B. review how the team will be evaluated.
- C. review the goals for the team.
- D. establish deadlines for the team.
Correct Answer: C
Rationale: Reviewing team goals (C) initially aligns members toward a common purpose, addressing poor dynamics by fostering collaboration. A code of conduct (A), evaluation methods (B), and deadlines (D) are important but secondary to establishing shared objectives.
The nurse is caring for assigned clients. After administering prescribed medications, the nurse should immediately intervene if the client reports
- A. nausea during an infusion of amphotericin B.
- B. palpitations after receiving rapid-acting insulin.
- C. drowsiness after receiving fentanyl.
- D. itching in the perineal area while receiving intravenous dexamethasone.
Correct Answer: B
Rationale: Palpitations after rapid-acting insulin (B) suggest hypoglycemia or an adverse reaction, requiring immediate intervention to assess and stabilize. Nausea with amphotericin B (A), drowsiness with fentanyl (C), and itching with dexamethasone (D) are expected side effects and less urgent.