Nokea
Nurse is caring for many clients during mass casualty event. Which client is highest priority?
- A. Client with crush injuries to chest/abdomen & expected to die
- B. Client with 4-inch laceration to head
- C. Client with partial & full-thickness burns to face, neck, chest
- D. Client with fractured fibula & tibia
Correct Answer: C
Rationale: The correct answer is C because clients with partial & full-thickness burns to face, neck, chest are the highest priority during a mass casualty event. This is due to the potential for airway compromise and risk of respiratory distress. Burns to these areas can cause swelling and compromise the airway, leading to respiratory distress and possible respiratory failure. Immediate intervention is crucial to ensure adequate oxygenation and ventilation. Clients with crush injuries (A) or fractures (D) may have serious injuries but are not at immediate risk of airway compromise. A laceration to the head (B) may require urgent attention but is not as life-threatening as airway compromise.
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Nurse receives prescription for antibiotic for client with cellulitis. Nurse checks client's med record, discovers she's allergic to it, & calls provider to request different one. Which of following attitudes did the nurse demonstrate?
- A. fairness
- B. responsibility
- C. risk taking
- D. creativity
Correct Answer: B
Rationale: The correct answer is B: responsibility. The nurse demonstrated responsibility by ensuring patient safety and advocating for a suitable alternative antibiotic after discovering the allergy. This action aligns with the nurse's duty to provide safe and effective care.
Other choices are incorrect:
A: Fairness doesn't apply as the nurse's action was based on patient safety, not fairness.
C: Risk-taking is not demonstrated; the nurse acted based on known risks of the allergic reaction.
D: Creativity is not applicable here; the nurse followed standard protocols for managing allergies.
Nurse has noticed several times in past week when another nurse on unit seemed drowsy & unable to focus. Today, she found nurse asleep in chair in break room when she was not on a break. Which of the following actions should nurse take?
- A. Remind nurse that safe client care is priority on unit
- B. Ask others on team whether they have seen same behavior
- C. Report observations to nurse manager on unit
- D. Conclude her coworker's fatigue is not her problem to solve
Correct Answer: C
Rationale: The correct answer is C: Report observations to nurse manager on unit. This is the best course of action as it prioritizes patient safety and addresses the potential risk of a drowsy and unfocused nurse providing care. Reporting to the nurse manager is important to ensure proper intervention and support for the drowsy nurse.
Choice A: Reminding the nurse of safe client care is important but does not address the root cause of the behavior.
Choice B: Asking others on the team may provide additional insights but does not address the immediate need to ensure patient safety.
Choice D: Concluding that the coworker's fatigue is not her problem to solve neglects the responsibility to advocate for patient safety.
Overall, choice C is the most appropriate action to take in this situation to address the potential risk to patient care.
When entering a client's room to change a dressing, the nurse notes the client is coughing & sneezing. When preparing a sterile field, it's important the nurse...
- A. Keep sterile field at least 6 ft away from client's bedside
- B. Instruct client to not cough/sneeze during dressing change
- C. Place mask on client to limit the spread of microorganisms into the surgical wound
- D. Keep box of Kleenex nearby for client to use during dressing change
Correct Answer: C
Rationale: The correct answer is C because placing a mask on the client helps limit the spread of microorganisms into the surgical wound. This is crucial to prevent infection. Choice A is incorrect because the distance does not necessarily prevent microorganism spread. Choice B is unrealistic as it's difficult for a client to control coughing/sneezing. Choice D does not address the prevention of microorganism spread.
Nurse educator is discussing facility protocol for tornados with staff. Which should nurse include in instructions? (Select all that apply.)
- A. Open doors to client rooms
- B. Place blankets over clients who are confined to beds
- C. Move beds away from windows
- D. Draw shades & close drapes
- E. Relocate ambulatory clients in hallways back to rooms
Correct Answer: B,C,D
Rationale: The correct answers are B, C, and D. B: Placing blankets over confined clients helps protect them from debris. C: Moving beds away from windows reduces the risk of injury from shattered glass. D: Drawing shades and closing drapes can prevent glass from shattering and flying into the room. A: Opening doors to client rooms can increase the risk of debris entering and injuring clients. E: Relocating ambulatory clients back to rooms can expose them to more danger in case of a tornado.
Nurse caring for 5 yo whose parents report she fears painful procedures, like shots. Which strategies should nurse use to try to help ease child's fear? (Select all that apply.)
- A. Invite child to assist with mealtime activities
- B. Cluster invasive procedures whenever possible
- C. Assign caregivers with whom the child is familiar
- D. Have parents bring in favorite toy from home
- E. Engage child in pretend play with toy medical kit
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
A: Inviting the child to assist with mealtime activities can help build trust and rapport, making the child more comfortable and less fearful in the healthcare setting.
D: Having parents bring in the child's favorite toy from home can provide comfort and distraction, helping to alleviate fear and anxiety during procedures.
E: Engaging the child in pretend play with a toy medical kit allows for familiarization with medical tools in a non-threatening way, helping to reduce fear and anxiety related to medical procedures.
Summary:
B: Clustering invasive procedures may minimize the number of times the child needs to undergo such procedures but does not directly address the fear.
C: Assigning caregivers familiar to the child is important for comfort but may not directly address the fear of painful procedures.