Nokea
The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority?
- A. Monitor for specific symptoms.
- B. Manage all patients using standard precautions.
- C. Transport patients quickly and efficiently through the elevators.
- D. Prepare for post-traumatic stress associated with this bioterrorism attack.
Correct Answer: B
Rationale: The correct answer is B: Manage all patients using standard precautions. This is the priority action because in a potential bioterrorism attack, protecting both patients and staff from exposure to any harmful agents is crucial. Standard precautions help prevent the spread of infections and ensure safety for everyone in the emergency department. Monitoring for specific symptoms (choice A) is important but comes after ensuring immediate safety. Transporting patients quickly (choice C) may increase the risk of spreading potential agents. Preparing for post-traumatic stress (choice D) is important but not the priority in the initial response to a bioterrorism threat.
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The nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym. Which questions will the nurse ask the patient? (Select all that apply.)
- A. Where did you fall?
- B. What time did the fall occur?
- C. What were you doing when you fell?
- D. What types of injuries occurred after the fall?
- E. Did you obtain an electronic safety alert device after the fall?
Correct Answer: A,B,C,D
Rationale: The correct answers are A, B, C, and D. Asking where, when, and what the patient was doing during the fall helps to assess the circumstances leading to the fall and potential risk factors. Inquiring about types of injuries provides insight into the severity of the fall and any complications. Choice E is incorrect as it focuses on post-fall actions rather than the fall event itself. The other choices, F and G, are not provided in the question and are therefore irrelevant.
A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately?
- A. Respiratory rate
- B. Temperature
- C. Apical pulse
- D. Blood pressure
Correct Answer: B
Rationale: The nurse should address the temperature (Choice B) immediately because it is below the normal range (normal range is around 97-99°F). A low body temperature, such as 94.8°F, can indicate hypothermia, which is a medical emergency requiring prompt intervention to prevent complications like organ dysfunction or cardiac arrest. Addressing the temperature first is crucial to prevent further deterioration of the patient's condition.
Other choices are not as urgent:
A: Respiratory rate (12 breaths per minute) is within the normal range.
C: Apical pulse (58 beats per minute) is slightly lower but not immediately life-threatening.
D: Blood pressure (106/56 mmHg) is on the lower side but not acutely concerning.
A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls?
- A. 55 years old
- B. 20/20 vision
- C. Urinary continence
- D. Orthostatic hypotension
Correct Answer: D
Rationale: The correct answer is D: Orthostatic hypotension. This finding puts the patient at risk for falls due to sudden drops in blood pressure when changing positions. Orthostatic hypotension can lead to dizziness, lightheadedness, and potential falls. A: Age alone does not necessarily indicate fall risk. B: Having 20/20 vision is not directly related to fall risk. C: Urinary continence does not directly indicate fall risk. Therefore, the correct choice is D as it directly correlates with an increased risk of falls.
The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event?
- A. No blood incompatibility occurs with a blood transfusion.
- B. A surgical sponge is left in the patient's incision.
- C. Pulmonary embolism after lung surgery.
- D. Stage II pressure ulcer.
Correct Answer: B
Rationale: The correct answer is B because leaving a surgical sponge in a patient's incision is a Never Event - a preventable medical error that should never occur. Reporting this event is crucial for patient safety and quality care. Choices A, C, and D are not Never Events as they can occur despite adherence to best practices and guidelines. Choice A indicates a successful blood transfusion without complications, C is a known risk after lung surgery, and D can develop even with proper preventive measures.
The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take?
- A. Assess the patient.
- B. Gather restraint supplies.
- C. Try alternatives to restraint.
- D. Call the health care provider for a restraint order.
Correct Answer: A
Rationale: The correct answer is A: Assess the patient. The priority action is to assess the patient to determine the underlying cause of the sudden confusion and agitation. This will help the nurse identify any medical issues or discomfort causing the behavior, such as hypoxia, infection, or medication side effects. By assessing the patient first, the nurse can address the root cause of the behavior and implement appropriate interventions, which may include addressing the patient's needs, providing comfort measures, or involving other healthcare team members as needed. Gathering restraint supplies (B) should not be the initial action as it does not address the underlying cause of the behavior. Trying alternatives to restraint (C) is important but should come after assessing the patient. Calling the healthcare provider for a restraint order (D) should only be considered after other interventions have been attempted.