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The emergency department charge nurse was notified of a mass shooting at a nearby shopping mall. The nurse should take which action to prepare for the surge in clients? Select all that apply.
- A. Work to arrange timely discharge and admission for appropriate clients.
- B. Establish a holding area for discharged clients not able to go home.
- C. Modify the nurse/client ratio to accommodate the surge levels.
- D. Instruct staff to switch from electronic to paper documentation.
- E. Prepare to provide frequent updates to local media.
Correct Answer: A,B
Rationale: Timely discharges/admissions and a holding area optimize resources. Modifying nurse ratios, switching to paper documentation, or media updates are not primary actions.
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The nurse is recommending respite care to a client and their caregiver. The nurse understands that this care is designed to
- A. Improve the quality of life of clients and families who are experiencing problems related to life-threatening illnesses.
- B. Provide a variety of health and social services to specific patient populations.
- C. Have clients live with comfort, independence, and dignity while easing the pain of terminal illness.
- D. Offers short-term relief by providing caregivers who support the ill, disabled, or frail older adults time to relax.
Correct Answer: D
Rationale: Respite care provides temporary relief for caregivers, allowing them rest. Other options describe palliative or comprehensive care services.
The nurse is assessing a client who just returned from surgery. The nurse checks preoperative vital signs at 0830 to compare them with the current vital signs at 1030 . What action should the nurse take?
- A. Assess the surgical wound
- B. Collect blood cultures
- C. Administer oxygen at 2 L/minute
- D. Encourage by-mouth (PO) fluids
Correct Answer: C
Rationale: Changes in vital signs post-surgery may indicate respiratory or circulatory compromise. Administering oxygen at 2 L/minute is a prudent initial action to support oxygenation while further assessment occurs. Wound assessment, blood cultures, or fluids require specific clinical indications.
The nurse is teaching parents about fire safety in the home. Which of the following recommendations should the nurse make? Select all that apply.
- A. Use smoke detectors instead of carbon monoxide detectors
- B. Teach your child what the smoke detector sounds like and what to do when one is heard
- C. Teach children how to light a candle in the event of power failure
- D. Practice escaping from your home at least twice a year
- E. Ensure that electrical wiring is under rugs, not above them
- F. If a house fire occurs, call emergency services before evacuating
Correct Answer: B,D
Rationale: Teaching children about smoke detector sounds and escape actions, and practicing escape plans twice yearly, enhance fire safety. Both types of detectors are needed, candles pose risks, wiring under rugs is hazardous, and evacuation precedes calling services.
The nurse is observing a student collect vital signs on a client. Which action by the student requires the nurse to intervene? Select all that apply.
- A. Obtains the blood pressure with a cuff bladder width of at least 40% of arm circumference.
- B. Places the BP cuff over the client's clothing garment.
- C. Requests the client remove their hearing aid before obtaining a tympanic temperature.
- D. Assesses the client's respirations after obtaining the pulse rate.
- E. Obtains blood pressure by placing the client's upper extremity at the level of their heart.
- F. Places the pulse oximeter probe on the client's finger that has edema.
Correct Answer: B,F
Rationale: Placing the BP cuff over clothing and using an edematous finger for pulse oximetry can yield inaccurate readings. Other actions are correct.
The infection control nurse is responding to an outbreak of norovirus in the facility. The nurse should recommend that
- A. staff wears a surgical mask when providing client care.
- B. disposable utensils and dishware are used for meals.
- C. dietary staff wears a face shield when preparing client meals.
- D. commonly touched surfaces be disinfected with a bleach solution.
Correct Answer: D
Rationale: Norovirus requires contact precautions, including bleach disinfection of surfaces. Masks, disposable utensils, and face shields are not standard.