A patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first?
- A. Heart rate.
- B. Breath sounds.
- C. Body temperature.
- D. Level of consciousness.
Correct Answer: C
Rationale: The correct answer is C: Body temperature. In a patient who has fallen through the ice, hypothermia is a major concern due to exposure to cold water. Assessing body temperature first is crucial to determine the severity of hypothermia and guide immediate interventions. Heart rate, breath sounds, and level of consciousness can be affected by hypothermia but are secondary assessments. Assessing body temperature is the priority to address the most life-threatening issue first.
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A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, 'I had a temperature of 103.9°F (39.9°C) at home.' The nurse’s first action should be to:
- A. Assess the patient’s current vital signs.
- B. Give acetaminophen (Tylenol) per agency protocol.
- C. Ask the patient to provide clean-catch urine for urinalysis.
- D. Tell the patient that it will be 1 to 2 hours before being seen by the doctor.
Correct Answer: A
Rationale: The correct answer is A: Assess the patient's current vital signs. The nurse's first action should be to gather objective data to assess the patient's condition and determine the urgency of the situation. Vital signs, including temperature, heart rate, blood pressure, and respiratory rate, provide crucial information for the initial assessment. This will help the nurse identify any signs of sepsis, shock, or other serious conditions that require immediate intervention.
The other choices are incorrect because:
B: Giving acetaminophen without assessing the patient's vital signs and determining the cause of the symptoms could mask important clinical information and delay appropriate treatment.
C: While obtaining a urine sample may be necessary later to rule out a urinary tract infection, it is not the most immediate priority in this case.
D: Delaying the patient's assessment and care based on estimated wait times is not appropriate when the patient presents with potentially serious symptoms. Immediate evaluation is required in this scenario.
The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily assignment?
- A. Tracheostomy tube suctioning.
- B. Medication administration.
- C. Colostomy care instruction.
- D. Client personal hygiene.
Correct Answer: B
Rationale: The correct answer is B: Medication administration. This is the priority because medication administration is time-sensitive and crucial for patient safety. It requires precise timing and cannot be delayed. Tracheostomy tube suctioning (A), colostomy care instruction (C), and client personal hygiene (D) are important nursing activities but can be adjusted within the schedule based on patient needs and acuity levels. Prioritizing medication administration ensures that patients receive their medications on time, preventing adverse events and promoting optimal health outcomes.
As part of nursing management of a critically ill patient, o rders are written to keep the head of the bed elevated at 30 degrees, awaken the patient from se dation each morning to assess readiness to wean from mechanical ventilation, and implement oral care protocols every 4 hours. These interventions are done as a group to reduce thabei rrbi.csokm o/tef svt entilator-associated pneumonia. This group of evidence-based interventions is often referred to using what term?
- A. Bundle of care.
- B. Clinical practice guideline.
- C. Patient safety goal.
- D. Quality improvement initiative.
Correct Answer: A
Rationale: The correct answer is A: Bundle of care. A bundle of care refers to a set of evidence-based interventions that, when implemented together, have been shown to improve patient outcomes. In this scenario, keeping the head of the bed elevated, daily awakening from sedation, and oral care protocols are bundled together to reduce the risk of ventilator-associated pneumonia. This approach is based on the idea that implementing multiple interventions simultaneously is more effective than individual interventions alone.
Choices B, C, and D are incorrect because:
B: Clinical practice guidelines provide recommendations for healthcare providers based on evidence but do not necessarily involve a group of interventions bundled together.
C: Patient safety goals are specific objectives aimed at improving patient safety outcomes, but they do not specifically refer to a group of interventions bundled together.
D: Quality improvement initiatives focus on improving processes and outcomes in healthcare settings but do not necessarily involve a group of interventions bundled together for a specific purpose like in this case.
A client has been admitted after experiencing multiple trauma and is intubated and sedated. When the five members of the immediate family arrive, they are anxious, angry, and very demanding. They all speak loudly at once and ask for many services and answers. What is the best nursing response?
- A. Ask the family to leave until visiting hours begin.
- B. Take them to a private area for initial explanations.
- C. Page security to have them removed from unit.
- D. Show them to the clients bedside and leave them alone.
Correct Answer: B
Rationale: The correct answer is B: Take them to a private area for initial explanations. This response is the best because it allows the nurse to address the family's concerns in a private and controlled environment. It promotes effective communication and enables the family to express their emotions and receive information without distractions.
Choice A is incorrect because asking the family to leave may escalate the situation and not address their needs. Choice C is inappropriate as paging security to remove the family can worsen the family's distress and hinder communication. Choice D is not ideal as leaving the family alone may lead to misunderstandings and increased anxiety. Overall, choice B is the most therapeutic and effective approach in this situation.
The VALUE mnemonic is a helpful strategy to enhance communication with family members of critically ill patients. Which of the following statements describes a VALUE strategy?
- A. View the family as guests on the unit.
- B. Acknowledge family emotions.
- C. Learn as much as you can about family structure and f unction.
- D. Use a trained interpreter if the family does not speak English.
Correct Answer: B
Rationale: The correct answer is B: Acknowledge family emotions. This is a key component of the VALUE strategy as it emphasizes empathy and understanding towards the emotions that family members may be experiencing during a difficult time. By acknowledging their emotions, healthcare providers can build trust and establish a supportive relationship with the family.
Choice A is incorrect because the VALUE strategy focuses on treating family members as integral members of the care team, not just as guests. Choice C is incorrect as learning about family structure and function is important but not specifically part of the VALUE strategy. Choice D is incorrect as using a trained interpreter is important for effective communication but is not specific to the VALUE mnemonic.