Nokea
Nursing instructor is reviewing which actions nurses can initiate w/o provider's prescription. Students should identify which of following as nurse-initiated? (Select all that apply.)
- A. Give morphine sulfate 1-2 mg IV every 1h as needed for pain
- B. Insert NG tube to relieve client's gastric distension
- C. Show client how to use progressive muscle relaxation
- D. Perform daily bath after evening meal
- E. Re-position client every 2h to reduce pressure ulcer risk
Correct Answer: C, D, E
Rationale: Correct Answer: C, D, E
Rationale:
C: Showing a client how to use progressive muscle relaxation is an example of a nurse-initiated action as it involves client education and does not require a provider's prescription.
D: Performing a daily bath after the evening meal is a routine nursing care activity that can be initiated by the nurse without a provider's prescription.
E: Re-positioning a client every 2 hours to reduce the risk of pressure ulcers is an essential nursing intervention that can be initiated by the nurse without a provider's prescription.
Summary of Incorrect Choices:
A: Giving morphine sulfate IV every 1 hour as needed for pain requires a provider's prescription due to the administration of a controlled substance.
B: Inserting an NG tube to relieve gastric distension is an invasive procedure that typically requires a provider's order and specialized training.
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Nurse is caring for many clients during mass casualty event. Which client is highest priority?
- A. Client with crush injuries to chest/abdomen & expected to die
- B. Client with 4-inch laceration to head
- C. Client with partial & full-thickness burns to face, neck, chest
- D. Client with fractured fibula & tibia
Correct Answer: C
Rationale: The correct answer is C because clients with partial & full-thickness burns to face, neck, chest are the highest priority during a mass casualty event. This is due to the potential for airway compromise and risk of respiratory distress. Burns to these areas can cause swelling and compromise the airway, leading to respiratory distress and possible respiratory failure. Immediate intervention is crucial to ensure adequate oxygenation and ventilation. Clients with crush injuries (A) or fractures (D) may have serious injuries but are not at immediate risk of airway compromise. A laceration to the head (B) may require urgent attention but is not as life-threatening as airway compromise.
Nurse counseling middle adult who describes having difficulty with many issues. Which problem should nurse identify as priority for more assessment & intervention?
- A. "I'm struggling to accept my parents are aging & need so much help"
- B. It's been so stressful for me to think about having intimate relationships
- C. I know I should volunteer my time for good cause, but maybe I'm just selfish
- D. I love my grandchildren, but my son expects me to relive my parenting days
Correct Answer: B
Rationale: The correct answer is B. The nurse should prioritize assessing and intervening in the middle adult's difficulty with intimate relationships because it can significantly impact their emotional well-being and ability to form healthy connections. Intimate relationships play a crucial role in one's overall quality of life and can affect various aspects of mental health. By addressing this issue first, the nurse can help the individual work through their stress and potentially improve their relationships and overall psychological health.
Choices A, C, and D are not as critical as choice B because they involve different aspects of the individual's life that may not have an immediate impact on their emotional well-being and relationships. While accepting aging parents or volunteering are important, they do not directly address the middle adult's current emotional distress. Similarly, the expectation from the son regarding grandparenting, while challenging, may not be as urgent as addressing the stress related to intimate relationships.
Nurse contributing to a care plan for a client being admitted to a facility with suspected pertussis. Which should the nurse include in the care plan? (Select all that apply.)
- A. Place client in a room with negative air pressure of at least 6 exchanges per hour
- B. Wear mask when providing care within 3 ft of client
- C. Place mask on client if transportation to another department is unavoidable
- D. Use sterile gloves when handling soiled linens
- E. Wear gown when performing care that may result in contamination from secretions
Correct Answer: B,C,E
Rationale: The correct answers are B, C, and E.
B: Wearing a mask within 3 ft of the client helps prevent the spread of pertussis, which is transmitted through respiratory secretions.
C: Placing a mask on the client during transportation reduces the risk of spreading the infection to others.
E: Wearing a gown during care that may result in contamination from secretions further prevents transmission.
A: Negative air pressure is not necessary for pertussis transmission control.
D: Sterile gloves are not required for handling soiled linens in pertussis cases.
In summary, the correct answers focus on preventing the spread of pertussis through respiratory secretions, while the incorrect choices are not directly related to infection control measures for this condition.
Nurse is preparing in-service program about delegation. Which of following elements should she identify when presenting 5 rights of delegation? (Select all that apply.)
- A. Right client
- B. Right supervision/evaluation
- C. Right direction/communication
- D. Right time
- E. Right circumstances
Correct Answer: B, C, E
Rationale: The correct answer is B, C, and E. Right supervision/evaluation ensures appropriate oversight, right direction/communication is crucial for clear instructions, and right circumstances involve assessing if it is appropriate to delegate the task. Right client is not directly related to delegation, and right time is not one of the traditional 5 rights of delegation.
Nurse is receiving provider prescription by phone for morphine for client who is reporting moderate to severe pain. Which of the following actions are appropriate? (Select all that apply.)
- A. Repeat details of prescription back to provider
- B. Have another nurse listen to phone prescription
- C. Obtain prescriber’s signature on prescription within 24 hours
- D. Decline verbal prescription b/c it is not emergency situation
- E. Tell charge nurse that the provider has prescribed morphine by phone
Correct Answer: A, B, C
Rationale: Correct Answer: A, B, C
Rationale:
A: Repeating details back ensures accurate transcription and comprehension.
B: Having another nurse listen ensures a second verification of the prescription.
C: Obtaining the prescriber's signature within 24 hours ensures legal compliance and accountability.
Incorrect Choices:
D: Declining the prescription could delay pain relief for the client.
E: Informing the charge nurse alone does not ensure proper documentation and accountability.