Nokea
The nurse observes a client looking frightened and reporting, 'feeling out of control.' Which therapeutic approach by the nurse is most appropriate to maintain a safe environment?
- A. Administer a PRN antianxiety medication immediately.
- B. Provide isolation for the client in the unit's 'time-out' room.
- C. Observe the client in an ongoing manner but do not intervene.
- D. Encourage the client to talk about her or his feelings in a quiet setting.
Correct Answer: D
Rationale: The anxiety symptoms demonstrated by this client require some form of intervention. Moving the client to a quiet setting decreases environmental stimuli. Talking provides the nurse an opportunity to assess the cause of the client's feelings and identify appropriate interventions. Medication is used only when other noninvasive approaches have been unsuccessful. Isolation is appropriate if a client is a danger to self or others.
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The nurse prepares a client being discharged from the hospital to receive oxygen therapy at home. Which action should the nurse include in client teaching about oxygen safety?
- A. Holding the oxygen tank on your lap when traveling
- B. Checking the oxygen level of the tank on a regular basis
- C. Lighting candles at least a few feet away from the oxygen tank
- D. Reporting low oxygen levels in the tank to the primary health care provider (HCP)
Correct Answer: B
Rationale: The nurse instructs the client and family to check the oxygen level in the tank on a regular basis to prevent the oxygen from running out. When traveling, the oxygen tank should be secured in place to prevent tank damage and a potentially devastating injury from a moving tank. Oxygen is a highly combustible gas, and, although it will not spontaneously burn or cause an explosion, it contributes to a fire if it contacts a spark from a cigarette, burning candle, or electrical equipment. The nurse instructs the client to contact the oxygen supplier about low oxygen levels in the tank; contacting the HCP is likely to delay prompt replacement of the oxygen tank.
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).
A client with a diagnosis of thrombophlebitis is being treated with prescribed heparin sodium therapy. In planning a safe environment, the nurse should ensure that which medication is available if the client develops a significant bleeding problem?
- A. Retaplase
- B. Phytonadione
- C. Protamine sulfate
- D. Fresh frozen plasma
Correct Answer: C
Rationale: Protamine sulfate is the antidote for heparin sodium. Fresh frozen plasma may be used for bleeding related to warfarin therapy. Retaplase is a thrombolytic agent used to dissolve blood clots. Phytonadione is the antidote for warfarin.
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.
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.