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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.
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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.
A gastric lavage has been ordered for a client who is comatose and who ingested a full bottle of acetaminophen, a nonnarcotic analgesic. Which intervention should be included in the procedure? Select all that apply.
- A. Place the client on the left side with the head 15 degrees lower than the body.
- B. Insert a small-bore feeding tube into the naris.
- C. Have standby suction available.
- D. Withdraw stomach contents and then instill an irrigating solution.
- E. Send samples of the stomach contents to the laboratory for analysis.
Correct Answer: A,C,D,E
Rationale: Left-side positioning with head down prevents aspiration, suction clears secretions, withdrawing and irrigating removes poison, and lab analysis confirms ingestion. Small-bore tubes are inadequate for lavage.
The ED nurse is caring for a client with fractured pelvis and bladder trauma secondary to a motor-vehicle accident. Which data are most important for the nurse to assess?
- A. Monitor the creatinine and BUN.
- B. Check urine output hourly.
- C. Note the amount and color of the urine.
- D. Assess for bladder distention.
Correct Answer: C
Rationale: Amount and color of urine (e.g., hematuria) indicate bladder trauma severity, guiding intervention. Creatinine/BUN, output, and distention are important but secondary.
The nurse is caring for clients on a medical floor. Which client is most likely to experience sudden cardiac death?
- A. The 84-year-old client exhibiting uncontrolled atrial fibrillation.
- B. The 60-year-old client exhibiting asymptomatic sinus bradycardia.
- C. The 53-year-old client exhibiting ventricular fibrillation.
- D. The 65-year-old client exhibiting supraventricular tachycardia.
Correct Answer: C
Rationale: Ventricular fibrillation is a lethal arrhythmia causing sudden cardiac death if untreated. Atrial fibrillation, bradycardia, and SVT are less immediately fatal.
Which is the primary goal of the ED nurse in caring for a client who has ingested poison?
- A. Remove or inactivate the poison before it is absorbed.
- B. Provide long-term supportive care to prevent organ damage.
- C. Administer an antidote to increase the effects of the poison.
- D. Implement treatment prolonging the elimination of the poison.
Correct Answer: A
Rationale: Removing or inactivating the poison (e.g., via lavage or charcoal) prevents absorption, the primary goal. Supportive care, antidotes, and elimination are secondary.