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The client with partial-thickness (second-degree) and full-thickness (third-degree) burns is at risk of infection. What intervention has the highest priority in decreasing the client's risk of infection?
- A. Administration of plasma expanders
- B. Use of careful handwashing technique
- C. Application of a topical antibacterial cream
- D. Limiting visitors to the client with burns
Correct Answer: B
Rationale: The correct answer is the use of careful handwashing technique. Proper handwashing is the most effective way to prevent the transmission of infectious organisms. Option A, administration of plasma expanders, addresses hypovolemia in burn patients but does not directly decrease the risk of infection. Option C, application of a topical antibacterial cream, is beneficial but not as effective as proper handwashing in preventing infection. Option D, limiting visitors, may help reduce the risk of exposure to pathogens but is not as critical as ensuring healthcare providers maintain strict hand hygiene, which is the cornerstone of infection control in any healthcare setting.
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The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next?
- A. Document that the client responds to the painful stimulus.
- B. Observe the client's response to verbal stimulation.
- C. Place the client on seizure precautions for 24 hours.
- D. Report decorticate posturing to the health care provider.
Correct Answer: A
Rationale: The correct action for the nurse to take next is to document that the client responds to the painful stimulus. In this scenario, the client has shown a purposeful response to pain by wincing and pulling away, which should be accurately documented. Verbal stimulation assessment typically follows the assessment of responses to painful stimuli. Placing the client on seizure precautions is not warranted based solely on the observed response to a painful stimulus. Decorticate posturing, which involves abnormal flexion movements, is not demonstrated by the client in this case, making it unnecessary to report to the provider.
During the evacuation of a group of clients from a medical unit due to a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. What action should the nurse take?
- A. Assign an unlicensed assistive person to transport the client via a wheelchair.
- B. Remind the client to walk carefully down the stairs until reaching a lower floor.
- C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator.
- D. Open the closest fire doors so that ambulatory clients can evacuate more rapidly.
Correct Answer: B
Rationale: During the evacuation of a unit due to a fire, ambulatory clients should be evacuated via the stairway if possible and reminded to walk carefully to ensure their safety. They do not necessarily require assistance via a wheelchair. Elevators should not be used during a fire evacuation as they can pose a risk, and fire doors should be kept closed to contain the fire and smoke, preventing its spread to other areas of the building. Therefore, reminding the client to walk carefully down the stairs is the most appropriate action in this situation. Assigning an unlicensed assistive person to transport the client via a wheelchair may delay the evacuation process and put both individuals at risk. Asking the client to help by assisting a wheelchair-bound client to an elevator is not safe during a fire evacuation. Opening fire doors indiscriminately can lead to the spread of fire and smoke, endangering the clients and staff further.
A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?
- A. Americans with Disabilities Act of 1990
- B. ANA Code of Ethics with Interpretive Statements
- C. ANA's Scope and Standards of Nursing Practice
- D. Patient's Bill of Rights of 1990
Correct Answer: C
Rationale: The correct document the nurse should use to develop the unit's nursing guidelines for the mental health services department is ANA's Scope and Standards of Nursing Practice. This document specifically outlines the philosophy and standards of nursing practice, including psychiatric nursing. Option A, the Americans with Disabilities Act of 1990, and option D, the Patient's Bill of Rights of 1990, focus on client rights and legal protections rather than nursing practice guidelines. Option B, the ANA Code of Ethics with Interpretive Statements, provides ethical guidelines for nursing practice but does not specifically address the development of nursing guidelines for a mental health services department.
The client with cholecystitis is being instructed about dietary choices. Which meal best meets the dietary needs of this client?
- A. Steak, baked beans, and a salad
- B. Broiled fish, green beans, and an apple
- C. Pork chops, macaroni and cheese, and grapes
- D. Avocado salad, milk, and angel food cake
Correct Answer: B
Rationale: Clients with cholecystitis, which is inflammation of the gallbladder, should follow a low-fat diet to reduce symptoms. Broiled fish, green beans, and an apple (Option B) is the most suitable choice as it is low in fat. Steak, baked beans, and a salad (Option A) provide a high amount of fat and protein, which may exacerbate symptoms of cholecystitis. Pork chops, macaroni and cheese, and grapes (Option C) and avocado salad, milk, and angel food cake (Option D) contain high-fat foods that are not recommended for individuals with cholecystitis. Therefore, Option B is the most appropriate choice for a client with cholecystitis.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?
- A. Apply a warm compress proximal to the site.
- B. Check for kinks in the tubing and raise the IV pole.
- C. Adjust the tape that stabilizes the needle.
- D. Change the IV solution bag.
Correct Answer: B
Rationale: When a nurse assesses a slowed IV rate by gravity with a healthy venous access site in a 2-year-old admitted for dehydration, the next step would be to check for kinks in the tubing and raise the IV pole. This action ensures that the IV fluid can flow freely and reach the patient at the correct rate. Applying a warm compress proximal to the site (Choice A) is not indicated in this situation as it does not address the underlying issue of a slowed IV rate due to mechanical factors. Adjusting the tape that stabilizes the needle (Choice C) or changing the IV solution bag (Choice D) are not the priority actions in this case. These choices do not address the issue of a slowed IV rate caused by kinks in the tubing or the height of the IV pole, which are more likely reasons for the problem observed.