Nokea
The nurse is discussing mass casualties with a group of nursing students. Which statement by the student would indicate effective understanding? Select all that apply.
- A. Mass casualties are events that overwhelm local medical capabilities.
- B. When a mass casualty occurs, there is a need to increase the staff at the hospital.
- C. Many local agencies will collaborate to handle a mass casualty situation.
- D. An example of a mass casualty event is a fight between visitors in the intensive care unit.
- E. Staff preferences for client assignments should prioritize over client needs.
Correct Answer: A,B,C
Rationale: Mass casualties overwhelm resources, require more staff, and involve multi-agency collaboration. A visitor fight is not a mass casualty, and client needs take priority.
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The emergency department (ED) charge nurse is preparing for a surge of clients diagnosed with Ebola virus disease (EVD). The nurse should plan to take which action? Select all that apply.
- A. Implement visitor restrictions for affected clients
- B. Log entry and exit of all healthcare workers who provide care
- C. Ensure that bleach disinfectant wipes are available in each room
- D. Provide reusable personal protective equipment
- E. Have an observer for donning and doffing of personal protective equipment
Correct Answer: A,B,E
Rationale: Visitor restrictions, logging healthcare worker movements, and an observer for PPE donning/doffing are critical for EVD control. Bleach wipes are insufficient, and reusable PPE is not recommended.
The nurse is teaching a parenting class on infant car seat safety. Which statements should the nurse include? Select all that apply.
- A. Place the car seat rear-facing in the back seat and at 90 degrees.
- B. The car seat straps should fit snugly over the shoulders.
- C. Infants should ride in a car seat, rear-facing, in the back seat, until six months.
- D. Rolled blankets may be needed between the crotch and legs to prevent slouching.
- E. You may add padding underneath the infant to increase their comfort.
Correct Answer: B,D
Rationale: Snug straps and rolled blankets for positioning are correct. Rear-facing should be until at least 2 years, not 90 degrees, and padding underneath is unsafe.
The nurse is caring for a client who repeatedly attempts to get up from their wheelchair unassisted and has fallen twice. The primary healthcare provider (PHCP) prescribes restraints. Which type of restraint does the nurse anticipate?
- A. Soft wrist restraints
- B. Mitten restraints
- C. Seclusion
- D. Waist belt restraint
Correct Answer: D
Rationale: A waist belt restraint prevents unassisted standing while allowing some mobility. Wrist or mitten restraints limit hand use, and seclusion is inappropriate for fall prevention.
The nurse is caring for a client immediately following scleral buckling surgery for a retinal detachment of the right eye. Which of the following actions would be appropriate for the nurse to take?
- A. Place the client in a prone position
- B. Approach the client from the left side
- C. Instruct the client to perform deep breathing and coughing exercises
- D. Instruct client to avoid bending down
- E. Orientate the client to the environment
- F. Obtain a prescription for a stool softener
Correct Answer: B,D,E,F
Rationale: Post-scleral buckling surgery, the client’s positioning depends on the surgeon’s orders, but prone positioning is often avoided to prevent pressure on the eye. Approaching from the left side preserves the client’s intact visual field. Deep breathing and coughing may increase intraocular pressure and are typically avoided. Avoiding bending down prevents increased intraocular pressure. Orienting the client to the environment promotes safety due to potential vision changes. A stool softener prevents straining, which could increase intraocular pressure.
The nurse is developing a care plan for a child scheduled to be admitted to the oncology unit to receive treatment for leukemia. To facilitate effective transition to the hospitalized environment, the nurse should recommend that the parents
- A. Purchase new toys for the child.
- B. Allow flexibility in the daily routine, so it changes often.
- C. Bring in the child's favorite toys from home.
- D. Limit parental visitation to specific times.
Correct Answer: C
Rationale: Familiar toys provide comfort, easing the hospital transition. New toys lack familiarity, flexible routines disrupt stability, and limited visitation increases anxiety.