Nokea
The emergency department (ED) charge nurse is preparing for a surge of clients diagnosed with Ebola virus disease (EVD). The nurse should plan to take which action? Select all that apply.
- A. Implement visitor restrictions for affected clients
- B. Log entry and exit of all healthcare workers who provide care
- C. Ensure that bleach disinfectant wipes are available in each room
- D. Provide reusable personal protective equipment
- E. Have an observer for donning and doffing of personal protective equipment
Correct Answer: A,B,E
Rationale: Visitor restrictions, logging healthcare worker movements, and an observer for PPE donning/doffing are critical for EVD control. Bleach wipes are insufficient, and reusable PPE is not recommended.
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The nurse is caring for a client two days post-operative following gastroduodenostomy. After reviewing the clinical data, the nurse should take which action?
- A. obtain a prescription for an antihypertensive
- B. determine if the client's pain is being controlled
- C. assess the client's surgical wound for signs of infection
- D. notify the physician for concerns of hypovolemic shock
Correct Answer: D
Rationale: Without specific clinical data, the priority for a client two days post-gastroduodenostomy is to assess for hypovolemic shock, a potential complication due to bleeding or fluid loss from the surgical site. This is more urgent than pain control, wound infection assessment, or antihypertensive needs, which require specific clinical indicators.
The nurse recognizes which of the following may be used as an approved client identifier? Select all that apply.
- A. first and last name
- B. date of birth
- C. telephone number
- D. admission date
- E. medical record number
- F. age
Correct Answer: A,B,E
Rationale: First and last name, date of birth, and medical record number are approved identifiers per Joint Commission standards. Telephone number, admission date, and age are not.
The nurse is supervising a graduate nurse completing an incident report regarding a client who fell. Which of the following actions by the graduate nurse requires follow-up?
- A. Documents an objective description of what happened
- B. Indicates that a 2-inch laceration was present on the client's scalp
- C. Documents in the nursing note that an incident report was completed
- D. Indicates the follow-up actions taken
Correct Answer: C
Rationale: Documenting the incident report in the nursing note violates confidentiality; incident reports are separate from patient records.
The nurse is caring for a client eight hours following a total thyroidectomy. The nurse plans on obtaining an order to assess the client's serum
- A. potassium level
- B. calcium level
- C. sodium level
- D. glucose level
Correct Answer: B
Rationale: Total thyroidectomy can disrupt parathyroid function, leading to hypocalcemia due to decreased parathyroid hormone. Monitoring serum calcium levels is critical to detect and manage this complication. Potassium, sodium, and glucose levels are less directly affected by thyroidectomy.
The nurse is performing perineal care for a female client. It would be appropriate for the nurse to
- A. Clean the client from the anal area to the urethral area.
- B. Vigorously dry the area with a clean towel.
- C. Ensure that the client's door is kept closed during the procedure.
- D. Use warm water and a soap containing alcohol.
Correct Answer: C
Rationale: Closing the door ensures privacy during perineal care. Cleaning backward risks infection, vigorous drying irritates, and alcohol-soap is harsh.