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The patient has been diagnosed with a respiratory illness and reports shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. At which temperature range will the nurse set the thermostat?
- A. 60° to 64° F
- B. 65° to 75° F
- C. 15° to 17° C
- D. 25° to 28° C
Correct Answer: B
Rationale: The correct answer is B: 65° to 75° F. This temperature range is ideal for a patient experiencing respiratory distress as it helps maintain a comfortable environment without being too cold or too warm. Lower temperatures (choice A) can exacerbate breathing difficulties, while the temperature range in Celsius (choice C) is too low for comfort. The temperature range in choice D is too warm and may cause discomfort for the patient. It is important to maintain a moderate temperature to assist the patient in breathing comfortably.
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The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority?
- A. Monitor for specific symptoms.
- B. Manage all patients using standard precautions.
- C. Transport patients quickly.
- D. Prepare for post-traumatic stress.
Correct Answer: B
Rationale: The correct answer is B: Manage all patients using standard precautions. This is the priority action because in a potential bioterrorism attack, the safety of healthcare staff and patients is paramount. By implementing standard precautions, the nurse can help prevent the spread of any potential bioterrorism agent to other patients or staff. Monitoring for specific symptoms (choice A) can be important but comes after ensuring safety through infection control. Transporting patients quickly (choice C) may increase exposure risk. Preparing for post-traumatic stress (choice D) is important but not the priority in the immediate response to a potential bioterrorism attack.
The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event?
- A. No blood incompatibility occurs with a blood transfusion.
- B. A surgical sponge is left in the patient's incision.
- C. Pulmonary embolism after lung surgery.
- D. Stage II pressure ulcer.
Correct Answer: B
Rationale: The correct answer is B because leaving a surgical sponge in a patient's incision is a Never Event - a preventable medical error that should never occur. Reporting this event is crucial for patient safety and quality care. Choices A, C, and D are not Never Events as they can occur despite adherence to best practices and guidelines. Choice A indicates a successful blood transfusion without complications, C is a known risk after lung surgery, and D can develop even with proper preventive measures.
A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?
- A. Determining the need for restraints
- B. Assessing the patient's orientation
- C. Obtaining an order for a restraint
- D. Applying the restraint
Correct Answer: D
Rationale: The correct answer is D: Applying the restraint. The rationale is that applying restraints is a task that can be safely delegated to nursing assistive personnel as it involves following specific instructions and does not require complex decision-making. Nursing assistive personnel can be trained to apply restraints safely under the supervision of a registered nurse.
A: Determining the need for restraints requires clinical judgment and assessment skills, which should be done by the registered nurse.
B: Assessing the patient's orientation involves critical thinking and interpretation of assessment findings, which is outside the scope of practice for nursing assistive personnel.
C: Obtaining an order for a restraint requires communication with the healthcare provider and understanding of legal and ethical implications, which should be done by the registered nurse.
A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately?
- A. Respiratory rate
- B. Temperature
- C. Apical pulse
- D. Blood pressure
Correct Answer: B
Rationale: The nurse should address the temperature (Choice B) immediately because it is below the normal range (normal range is around 97-99°F). A low body temperature, such as 94.8°F, can indicate hypothermia, which is a medical emergency requiring prompt intervention to prevent complications like organ dysfunction or cardiac arrest. Addressing the temperature first is crucial to prevent further deterioration of the patient's condition.
Other choices are not as urgent:
A: Respiratory rate (12 breaths per minute) is within the normal range.
C: Apical pulse (58 beats per minute) is slightly lower but not immediately life-threatening.
D: Blood pressure (106/56 mmHg) is on the lower side but not acutely concerning.
The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take?
- A. Assess the patient.
- B. Gather restraint supplies.
- C. Try alternatives to restraint.
- D. Call the health care provider for a restraint order.
Correct Answer: A
Rationale: The correct answer is A: Assess the patient. The priority action is to assess the patient to determine the underlying cause of the sudden confusion and agitation. This will help the nurse identify any medical issues or discomfort causing the behavior, such as hypoxia, infection, or medication side effects. By assessing the patient first, the nurse can address the root cause of the behavior and implement appropriate interventions, which may include addressing the patient's needs, providing comfort measures, or involving other healthcare team members as needed. Gathering restraint supplies (B) should not be the initial action as it does not address the underlying cause of the behavior. Trying alternatives to restraint (C) is important but should come after assessing the patient. Calling the healthcare provider for a restraint order (D) should only be considered after other interventions have been attempted.