Nokea
The nursing administrator responds to a code situation. When assessing the situation, which role must the administrator ensure is performed for legal purposes and continuity of care of the client?
- A. A person is ventilating with an Ambu bag.
- B. A person is performing chest compressions correctly.
- C. A person is administering medications as ordered.
- D. A person is keeping an accurate record of the code.
Correct Answer: D
Rationale: Accurate code documentation is critical for legal accountability and continuity of care. Ventilation, compressions, and medications are clinical priorities but less legally binding.
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The charge nurse of the medical-surgical unit secured the crash cart during the code. Which intervention should the charge nurse implement after transferring the client to the intensive care unit?
- A. Reassign the clients on the floor because one is now gone.
- B. Call the family of the client who coded and let them know of the transfer.
- C. Make sure the crash cart is restocked.
- D. Hold a unit meeting to determine if anything could have been done differently during the code.
Correct Answer: C
Rationale: Restocking the crash cart ensures readiness for future emergencies, a priority post-code. Reassignment, family calls, and meetings are secondary.
The unlicensed assistive personnel (UAP) is performing cardiac compressions on an adult client during a code. Which behavior warrants immediate intervention by the nurse?
- A. The UAP has hand placement on the lower half of the sternum.
- B. The UAP performs cardiac compressions and allows for rescue breathing.
- C. The UAP depresses the sternum 0.5 to one (1) inch during compressions.
- D. The UAP asks to be relieved from performing compressions because of exhaustion.
Correct Answer: C
Rationale: Compressions should depress the sternum 2–2.4 inches; 0.5–1 inch is inadequate, requiring intervention. Correct hand placement, rescue breathing, and relief requests are appropriate.
The nurse in the emergency department has admitted five (5) clients in the last two (2) hours with complaints of fever and gastrointestinal distress. Which question is most appropriate for the nurse to ask each client to determine if there is a bioterrorism threat?
- A. Do you work or live near any large power lines?
- B. Where were you immediately before you got sick?
- C. Can you write down everything you ate today?
- D. What other health problems do you have?
Correct Answer: B
Rationale: Asking about recent locations identifies potential common exposure points, critical for bioterrorism. Power lines, food intake, and comorbidities are less relevant.
The nurse caring for a client with sepsis writes the client diagnosis of 'alteration in comfort R/T chills and fever.' Which intervention should be included in the plan of care?
- A. Ambulate the client in the hallway every shift.
- B. Monitor urinalysis, creatinine level, and BUN level.
- C. Apply sequential compression devices to the lower extremities.
- D. Administer an antipyretic medication every four (4) hours PRN.
Correct Answer: D
Rationale: Antipyretics (e.g., acetaminophen) address fever and chills, improving comfort. Ambulation, lab monitoring, and compression devices address other sepsis concerns, not comfort.
The nurse working in an outpatient clinic is caring for a client who is experiencing epistaxis. Which intervention should the nurse implement first?
- A. Take the client’s blood pressure in both arms.
- B. Hold the nose with thumb and finger for 15 minutes.
- C. Have the client sit with the head tilted back and hold a tissue.
- D. Prepare to administer silver nitrate, a cauterizing agent, with a packing applicator.
Correct Answer: B
Rationale: Holding the nose for 15 minutes stops bleeding, the first intervention for epistaxis. BP, head tilting back (risks aspiration), and cauterization are secondary.