Nokea
The nurse caring for a chronically ill client with a poor prognosis shows an understanding of the basic values that guide the implementation of a living will by asking which questions? Select all that apply.
- A. Are you planning to become an organ donor?
- B. Do you feel the need to discuss your end-of-life decisions with your family?
- C. Did you have the discussion with your son about being your health care surrogate?
- D. Can we discuss what will happen if you decide to refuse antibiotics if you get an infection?
- E. Have you given thought to whether you want cardiopulmonary resuscitation (CPR) measures if your condition worsens?
Correct Answer: B,D,E
Rationale: A living will lists the treatment that a client chooses to omit or refuse if the client becomes unable to make decisions and is terminally ill. The client may want to discuss her or his decisions with the family. Although both the living will and durable powers of attorney for health care are based on values of informed consent, autonomy over end-of-life decisions, and control over the dying process, living wills do not involve health care surrogates or the decision to donate organs.
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Which clinical situation should justifiably be viewed as an assault?
- A. The nurse threatens to apply restraints to a client who is exhibiting aggressive behavior.
- B. The client requests a medical discharge, but the nurse physically forces the client to stay.
- C. The charge nurse sends an email to a staff member that includes a poor performance evaluation about another person.
- D. The nurse overhears the primary health care provider making derogatory remarks to the client about the nurse's level of competency.
Correct Answer: A
Rationale: An assault occurs when a person puts another person in fear of a harmful or offensive act. Battery involves offensive touching or the use of force by a perpetrator without the permission of the victim. Defamation takes place when a falsehood is said (slander) or written (libel) about a person that results in injury to that person's good name and reputation.
At the scene of a train crash, the nurse triages the victims. Which clients should be coded for triage as most urgent or the first priority? Select all that apply.
- A. Is dead
- B. Has chest pain
- C. Has a leg sprain
- D. Has a chest wound
- E. Has multiple fractures
- F. Has full-thickness burns over 30% of the body
Correct Answer: B,D,F
Rationale: In a disaster situation, saving the greatest number of lives is the most important goal. During a disaster the nurse would triage the victims to maximize the number of survivors and sort the treatable from the untreatable victims. First priority victims (most urgent and coded red) have life-threatening injuries and are experiencing hypoxia or near hypoxia. Examples of injuries in this category are shock, chest wounds, internal hemorrhage, head injuries producing loss of consciousness, partial- or full-thickness burns over 20% of the body surface, and chest pain. Second priority victims (urgent and coded yellow) have injuries with systemic effects but are not yet hypoxic or in shock and can withstand a 2-hour wait without immediate risk (e.g., a victim with multiple fractures). Third priority victims (coded green) have minimal injuries unaccompanied by systemic complications and can wait for more than 2 hours for treatment (leg sprain). Dying or dead victims have catastrophic injuries, and the dying victims would not survive under the best of circumstances (coded black).
The nurse provides home care instructions to the mother of a child with a diagnosis of chickenpox about preventing the transmission of the virus. Which is the best statement for the nurse to include in the instructions?
- A. Isolate the child until the skin vesicles have dried and crusted.
- B. Ensure that the child uses a separate bathroom for elimination.
- C. Bring all household members to the clinic for a varicella vaccine.
- D. Request a prescription for antibiotics for all household members.
Correct Answer: A
Rationale: Chickenpox is caused by the varicella-zoster virus. The communicable period is from 1 to 2 days before the onset of the rash to 6 days after the first crop of vesicles, when crusts have formed. Transmission occurs by direct contact with secretions from the vesicles or contaminated objects, and via respiratory tract secretions. It is not transmitted via urine or feces. The recommended preventative schedule for receiving the varicella vaccine is at 12 to 15 months of age (first dose) and 4 to 6 years of age (second dose). It is not administered at the time of exposure to the virus. Antibiotics are not used to treat a viral infection. Rather, they are used for treating bacterial infections.
The nurse is working in the emergency department of a small local hospital when a client with multiple stab wounds arrives by ambulance. Which action by the nurse is contraindicated when handling potential legal evidence?
- A. Initiating a chain of custody log.
- B. Giving clothing and wallet to the family.
- C. Cutting clothing along seams, avoiding stab holes.
- D. Placing personal belongings in a labeled, sealed paper bag.
Correct Answer: B
Rationale: Potential evidence is never released to the family to take home. Basic rules for handling evidence include initiating a chain of custody log to track handling and movement of evidence, limiting the number of people with access to the evidence, and carefully removing clothing and placing personal belongings in a labeled, sealed paper bag to avoid destroying evidence. This also usually includes cutting clothes along seams, while avoiding areas where there are obvious holes or tears.
The nurse hangs a 1000-\mathrm{mL intravenous (IV) solution of \mathrm{D}_5W ( 5\% dextrose in water) at 9 am and sets the infusion controller device to administer 100 \mathrm{gtt} / \mathrm{min via microdrip infusion set (60 \mathrm{gtt}=1mL}) . On assessment of the IV infusion, the nurse expects that the remaining amount of solution in the IV bag at 2 \mathrm{pm will be represented at which level? Fill in the blank and round to the nearest whole number.
Correct Answer: 500
Rationale: The nurse hangs an IV solution at 9 am and sets the IV solution to infuse at 100 \mathrm{gtt} / \mathrm{min per microdrip. With a microdrip, gtt/min =\mathrm{mL} / \mathrm{hr infused. Therefore, 100 \mathrm{mL} / \mathrm{hr is being infused. A total of 500mL will be infused in the 5 elapsed hours. At 2 \mathrm{pm the nurse would expect 500mL of solution to be safely infused and 500mL to be remaining. Since this is a fill-in-the-blank question, the answer is 500 mL, which corresponds to option B for CSV formatting purposes.