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The nurse is triaging a client involved in a chemical spill at a local chemical plant. The nurse assesses the client as responsive but unable to walk, with a respiratory rate of 28 and capillary refill <2 seconds. It would be correct for the nurse to triage this client with a
- A. yellow tag.
- B. red tag.
- C. black tag.
- D. green tag.
Correct Answer: A
Rationale: A yellow tag (A) is appropriate for a responsive client unable to walk with stable vital signs (RR 28, capillary refill <2 sec), indicating urgent but not immediate life-threatening needs. Red (B) is for critical, black (C) for deceased, and green (D) for minor injuries.
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A nurse is caring for a client who speaks a language different from the healthcare team. Which action by the nurse best ensures effective communication with the client?
- A. Using family members as interpreters.
- B. Utilizing a professional interpreter provided by the healthcare facility.
- C. Attempting to communicate using basic words and gestures.
- D. Referring the client to a language class for healthcare professionals.
Correct Answer: B
Rationale: A professional interpreter (B) ensures accurate, confidential communication, per Joint Commission standards. Family interpreters (A) risk bias, gestures (C) are unreliable, and language classes (D) are impractical for immediate needs.
The nurse has become aware of the following client situations. The nurse should first see the client who is receiving
- A. chemotherapy via a peripherally inserted central catheter (PICC) and reports blistering at the site.
- B. a chemotherapy infusion and develops nausea and vomiting.
- C. oral chemotherapy and reports burning in their mouth while drinking orange juice.
- D. external beam radiation therapy (EBRT) and sitting with visitors in the family waiting room.
Correct Answer: A
Rationale: Blistering at a PICC site during chemotherapy (A) suggests extravasation, a medical emergency requiring immediate intervention to prevent tissue damage. Nausea and vomiting (B) and oral burning (C) are less urgent side effects. Sitting with visitors (D) is a normal activity and not concerning.
The nurse is planning a staff developmental conference about confidentiality. Which of the following scenarios should the nurse include as a violation of client confidentiality?
- A. Informing a visitor of the room number of a client admitted with pneumonia
- B. Telling a police officer who brought a client into the emergency department (ED) the urine drug screen results
- C. Notifying the pharmacist that a client is HIV positive and may have a potential drug interaction
- D. Informing local authorities that a client is suspected of being a victim of domestic violence
Correct Answer: B
Rationale: Sharing drug screen results with police (B) violates confidentiality without consent or legal mandate, per HIPAA. Room number (A) is not protected, HIV disclosure for care (C) is permitted, and reporting suspected abuse (D) is legally required.
The client has just been given an IV dose of morphine 6 mg for neuropathic pain. A few minutes later, the nurse notes that the client's respirations are now 8, and his blood pressure has dropped from 122/83 mmHg to 88/67 mmHg. Which nursing action is the most appropriate?
- A. Prepare for intubation.
- B. Prepare to administer a dopamine infusion.
- C. Administer naloxone.
- D. Start an IV infusion of normal saline.
Correct Answer: C
Rationale: Respiratory depression (RR 8) and hypotension post-morphine (C) indicate opioid overdose, requiring naloxone to reverse effects, per ACLS guidelines. Intubation (A), dopamine (B), and saline (D) are secondary or inappropriate without reversal.
The nurse is reviewing tasks for assigned clients. Which action is a priority to implement?
- A. Visual acuity test for a client reporting blurred vision in one eye.
- B. 12-lead electrocardiogram for a client reporting chest pain.
- C. Orthostatic vital signs for a client complaining of syncope.
- D. Discharge teaching for a client newly diagnosed with hypertension.
Correct Answer: B
Rationale: A 12-lead ECG for chest pain (B) is the priority to rule out life-threatening cardiac events like myocardial infarction. Blurred vision (A), syncope (C), and discharge teaching (D) are less urgent, as they are not immediately life-threatening.