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The nurse working on a medical nursing unit during an external disaster is called to assist with care for clients coming into the emergency department. Using principles of triage, the nurse should implement immediate care for a client with which injury?
- A. Fractured tibia
- B. Penetrating abdominal injury
- C. Bright red bleeding from a neck wound
- D. Open massive head injury, resulting in deep coma
Correct Answer: C
Rationale: The client with bright red (arterial) bleeding from a neck wound is in 'immediate' need of treatment to save the client's life. This client is classified as an emergent (life-threatening) client and would wear a color tag of red from the triage process. A green or 'minimal' (nonurgent) designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. The client with a penetrating abdominal injury would be tagged yellow and classified as 'urgent,' requiring intervention within 60 to 120 minutes. A designation of 'expectant' would be applied to the client with massive injuries and minimal chance of survival. This client would be color-coded 'black' in the triage process. The client who is color-coded 'black' is given supportive care and pain management but is given definitive treatment last.
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The nurse is planning care for a client with a diagnosis of acute glomerulonephritis. Which action should the nurse instruct the unlicensed assistive personnel (UAP) to implement in the care of the client?
- A. Ambulate the client frequently.
- B. Encourage a diet that is high in protein.
- C. Monitor the temperature every 2 hours.
- D. Remove the water pitcher from the bedside.
Correct Answer: D
Rationale: A client with acute glomerulonephritis commonly experiences fluid volume excess and fatigue. Interventions include fluid restriction, as well as monitoring weight and intake and output. The client may be placed on bed rest or at least encouraged to rest because a direct correlation exists among proteinuria, hematuria, edema, and increased activity levels. The diet is high in calories but low in protein. It is unnecessary to monitor the temperature as frequently as every 2 hours.
The registered nurse (RN) planning the assignments for the day is leading a team composed of a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Based on licensure, which client is most appropriate to assign to the LPN?
- A. A client diagnosed with dementia
- B. A 1-day postoperative mastectomy client
- C. A client who requires some assistance with bathing
- D. A client who requires some assistance with ambulation
Correct Answer: B
Rationale: Assignment of tasks must be implemented based on the job description of the LPN and UAP, the level of education and clinical competence, and state law. The 1-day postoperative mastectomy client will need care that requires the skill of a licensed nurse. The UAP has the skills to care for a client requiring noninvasive care such as a client with dementia, a client who requires some assistance with bathing, and a client who requires some assistance with ambulation.
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 planning the discharge instructions for an adult client who is a victim of family violence. The nurse should understand that it is most important that which information is included in the discharge plans?
- A. Instructions to call the police the next time the abuse occurs
- B. Exploration of the pros and cons of remaining with the abusive family member
- C. Specific information regarding 'safe havens' or shelters in the client's neighborhood
- D. Specific information about current opportunities to enroll in local selfdefense classes
Correct Answer: C
Rationale: For the victim of family violence, any of the options might be included in the discharge plan at some point if long-term therapy or a long-term relationship with the nurse is established. The question refers to an emergency department setting. It is most important to assist victims of abuse with identifying a plan for how to remove self from harmful situations should they arise again. An abused person is usually reluctant to call the police. It is not the best time for the nurse to explore the pros and cons of remaining with the abusive family member; additionally, this action does not ensure safety for the victim. Teaching the victim to fight back (as in the use of self-defense) is not the best action when dealing with a violent person.
The nurse is teaching a client with a diagnosis of cardiomyopathy about home care safety measures. Which instruction is most important for the nurse to include?
- A. Reporting pain
- B. Appropriate vasodilator administration
- C. Avoiding over-the-counter medications
- D. Moving slowly from a sitting to a standing position
Correct Answer: D
Rationale: Orthostatic changes can occur in the client with cardiomyopathy as a result of venous return obstruction. Sudden changes in blood pressure may lead to falls. Reporting pain, while important, is not directly related to the issue of safety. Vasodilators are not normally prescribed for the client with cardiomyopathy. Option 3, although important, is not directly related to the issue of safety.