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The nurse has applied the patch electrodes of an automatic external defibrillator (AED) to the chest of a client who is pulseless. The defibrillator has interpreted the rhythm to be ventricular fibrillation. Which priority action should the nurse prepare to implement next?
- A. Administer rescue breathing during the defibrillation.
- B. Perform cardiopulmonary resuscitation (CPR) for 1 minute before defibrillating.
- C. Charge the machine and immediately push the 'discharge' buttons on the console.
- D. Order any personnel away from the client, charge the machine, and defibrillate through the console.
Correct Answer: D
Rationale: If the AED advises to defibrillate, the nurse or rescuer orders all persons away from the client, charges the machine, and pushes both of the 'discharge' buttons on the console at the same time. The charge is delivered through the patch electrodes, and this method is known as 'hands-off' defibrillation, which is safest for the rescuer. The sequence of charges is similar to that of conventional defibrillation. Option 1 is contraindicated for the safety of any rescuer. Performing CPR delays the defibrillation attempt.
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The nurse is caring for the body and personal belongings of a client who died as a result of multiple gunshot wounds. Which actions should the nurse take to properly secure and handle legal evidence? Select all that apply.
- A. Place paper bags on the hands and feet.
- B. Give the clothing and wallet to the family.
- C. Cut clothing along the seams, avoiding bullet holes.
- D. Collect all personal items, including items from clothing pockets.
- E. Place wet clothing and personal belongings in a labeled, sealed plastic bag.
- F. Do not allow family members, significant others, or friends to be alone with the client.
Correct Answer: A,C,D,F
Rationale: Basic rules for securing and handling evidence include minimally handling the body of a deceased person; placing paper bags on the hands and feet and possibly over the head of a deceased person (protects trace evidence and residue); placing clothing and personal items in paper bags (plastic bags can destroy items because items can sweat in plastic); cutting clothes along seams, avoiding areas where there are obvious holes or tears; and collecting all personal items, including items from clothing pockets. Evidence is never released to the family to take home, and family members, significant others, or friends are not allowed to be alone with the client because of the possibility of kindizing any existing legal evidence.
The nurse is caring for a child with a diagnosis of intussusception. During care, the child passes a formed brown stool. Which action is most appropriate for the nurse to take at this time?
- A. Note the child's physical symptoms.
- B. Prepare the child for hydrostatic reduction.
- C. Prepare the child and parents for the possibility of surgery.
- D. Report the passage of a normal brown stool to the primary health care provider.
Correct Answer: D
Rationale: Intussusception is the telescoping of one portion of the bowel into another portion. Passage of a normally formed brown stool usually indicates that the intussusception has reduced itself. This is immediately reported to the primary health care provider, who may choose to alter the diagnostic or therapeutic plan of care. Although the nurse would note the child's physical symptoms, based on the data in the question, option 4 is the appropriate action. Hydrostatic reduction and surgery may not be necessary.
The nurse is preparing the client assignments for the day to a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Which clients should the nurse assign to the LPN because of client needs that cannot be met by UAP? Select all that apply.
- A. A client requiring frequent suctioning
- B. A client requiring a dressing change to the foot
- C. A client requiring range-of-motion exercises twice daily
- D. A client requiring reinforcement of teaching about a diabetic diet
- E. A client on bed rest requiring vital sign measurement every 4 hours
- F. A client requiring collection of a urine specimen for urinalysis testing
Correct Answer: A,B,D
Rationale: Delegation is the transferring to a competent individual the authority to perform a nursing task. When the nurse plans client assignments, he or she needs to consider the educational level and experience of the individual and the needs of the client. The LPN is trained to perform all the tasks indicated in the options; the clients who have needs that cannot be met by the UAP are those requiring suctioning, a dressing change, and reinforcement of teaching about a diabetic diet. UAP are trained to perform range-of-motion exercises, measure vital signs, and collect a urine specimen.
Upon transfer from the post-anesthesia care unit (PACU) after spinal fusion, which technique should the nurse use to transfer the client from the stretcher to the bed?
- A. A bath blanket and the assistance of four people
- B. A bath blanket and the assistance of three people
- C. A transfer board and the assistance of two people
- D. A transfer board and the assistance of four people
Correct Answer: D
Rationale: After spinal fusion, with or without instrumentation, the client is transferred from the stretcher to the bed using a transfer board and the assistance of four people. This permits optimal stabilization and support of the spine, while allowing the client to be moved smoothly and gently. Therefore, the remaining options are incorrect and unsafe.
The nurse is assigned to care for a client with a diagnosis of preeclampsia. The nurse should plan to implement which action to provide a safe environment?
- A. Maintain fluid and sodium restrictions.
- B. Take the client's vital signs every 4 hours.
- C. Turn off the room lights and draw the window shades.
- D. Encourage visits from family and friends for psychosocial support.
Correct Answer: C
Rationale: Clients with preeclampsia are at risk of developing eclampsia (seizures). Bright lights and sudden loud noises may initiate seizures in this client. A woman with preeclampsia should be placed in a dimly lighted, quiet, private room. Clients with preeclampsia have decreased plasma volume, and adequate fluid and sodium intake is necessary to maintain fluid volume and tissue perfusion. Vital signs need to be monitored more frequently than every 4 hours when preeclampsia is present. Visitors should be limited to allow for rest and prevent overstimulation.