Nokea
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants intervention by the nurse?
- A. The UAP places a urine specimen in a biohazard bag in the hallway.
- B. The UAP uses the alcohol foam hand cleanser after removing gloves.
- C. The UAP puts soiled linen in a plastic bag in the client’s room.
- D. The UAP obtains a disposable stethoscope for a client in an isolation room.
Correct Answer: A
Rationale: Urine specimens are not biohazardous unless visibly bloody; placing in a biohazard bag is incorrect and requires intervention. Hand cleansing, linen handling, and stethoscope use are appropriate.
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The client is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first?
- A. Start an IV with an 18-gauge catheter.
- B. Administer dopamine intravenous infusion.
- C. Obtain arterial blood gases (ABGs).
- D. Insert an indwelling urinary catheter.
Correct Answer: A
Rationale: Hypovolemic shock (suggested by symptoms) requires immediate IV access for fluid resuscitation. Dopamine requires IV access, ABGs are diagnostic, and urinary catheter monitors output but is secondary.
The ED nurse is caring for a client diagnosed with multiple rib fractures. Which data should the nurse include in the assessment?
- A. Level of orientation to time and place.
- B. Current use and last dose of medication.
- C. Symmetrical movement of the chest.
- D. Time of last meal the client ate.
Correct Answer: C
Rationale: Symmetrical chest movement assesses for complications like pneumothorax or flail chest in rib fractures. Orientation, medications, and meal timing are secondary.
The charge nurse has been notified that a disaster has occurred and that all possible clients should be discharged so the floor can receive the casualties. Which client should not be discharged?
- A. The 13-year-old client who is scheduled for a tonsillectomy.
- B. The 42-year-old client scheduled for an abdominal aorta aneurysm dissection.
- C. The 76-year-old client diagnosed with a pulmonary embolus whose INR is 2.9.
- D. The 80-year-old client who is refusing to assist in activities of daily living.
Correct Answer: C
Rationale: A pulmonary embolus with INR 2.9 (therapeutic) requires ongoing anticoagulation and monitoring, precluding discharge. Tonsillectomy, aneurysm surgery, and ADL refusal are less acute.
Which statement explains the scientific rationale for having emergency suction equipment available during resuscitation efforts?
- A. Gastric distention can occur as a result of ventilation.
- B. It is needed to assist when intubating the client.
- C. This equipment will ensure a patent airway.
- D. It keeps the vomitus away from the healthcare provider.
Correct Answer: C
Rationale: Suction equipment clears vomit or secretions, ensuring a patent airway during resuscitation. Gastric distention, intubation, and HCP protection are secondary concerns.
Which intervention is most important for the nurse to implement when participating in a code?
- A. Elevate the arm after administering medication.
- B. Maintain sterile technique throughout the code.
- C. Treat the client’s signs/symptoms; do not treat the monitor.
- D. Provide accurate documentation of what happened during the code.
Correct Answer: C
Rationale: Treating the client’s clinical presentation (not just monitor readings) ensures appropriate care. Arm elevation, sterile technique, and documentation are secondary during active resuscitation.