The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?
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Solution
Answer B is correct. Out of all these client, it is best to hold the pregnant client and the client with a broken arm and facial lacerations in the same room. The other clients need to be placed in separate rooms, so answers A, C and D are incorrect.
The home health nurse is planning for the day’s visits. Which client should be seen first?
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Solution
Answer: D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter
The client at highest risk for complications is the client with multiple sclerosis who is being treated with cortisone via the central line. The others are more stable. MRSA is Methicillin-Resistant Staphylococcus Aureus. Vancomycin is the drug of choice and is given at scheduled times to maintain blood levels of the drug.
- Options A, B, and C: These clients are more stable and can be seen later.
The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:
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Solution
File a formal reprimand
The next action after discussing the problem with the nurse is to document the incident by filing a formal reprimand.
Options A, C, and D: If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but these are not the first actions requested in the stem. A tort is a wrongful act to the client or his belongings and is not indicated in this instance.
Which information should be reported to the state Board of Nursing?
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Solution
The narcotic count has been incorrect on the unit for the past 3 days.
The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers A and C. The failure of the nursing assistant to care for the client with hepatitis might result in termination but is not of interest to the Joint Commission.
Which nurse should be assigned to care for the postpartum client with preeclampsia?
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Solution
The RN with 3 years of experience in labor and delivery
The nurse with 3 years of experience in labor and delivery knows the most about possible complications involving preeclampsia.
Option A: The nurse is a new staff to the unit hence lacking the experience needed.
Options C and D: These nurses lack sufficient experience with a postpartum client.
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority?
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Solution
Contacting the physician
The vital signs are abnormal and should be reported immediately.
Option A: Continuing to monitor the vital signs can result in deterioration of the client’s condition.
Option C: Asking the client how he feels will only provide subjective data.
Option D: Assigning an unstable client to an LPN is inappropriate.
Which assignment should not be performed by the licensed practical nurse?
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Solution
Starting a blood transfusion
The licensed practical nurse should not be assigned to begin a blood transfusion.
Options A, B, and C: The licensed practical nurse can insert a Foley catheter, discontinue a nasogastric tube, and collect sputum specimen.
The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with:
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Solution
Malpractice
The nurse could be charged with malpractice, which is failing to perform, or performing an act that causes harm to the client. Giving the infant an overdose falls into this category.
Option A: Negligence is failing to perform care for the client. a tort is a wrongful act committed
Option B: A tort is a wrongful act committed on the client or their belongings
Option C: Assault is a violent physical or verbal attack.
The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
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Solution
The client with Cushing’s disease
The client with Cushing’s disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immunosuppressed.
Option B: the client with diabetes poses no risk to other clients.
Option C: The client has an increase in growth hormone and poses no risk to himself or others.
Option D: The client has hypothyroidism or myxedema and poses no risk to others or himself.
The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?
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Solution
The client receiving linear accelerator radiation therapy for lung cancer
The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy travels to the radium department for therapy. The radiation stays in the department, so the client is not radioactive. These clients are radioactive in very small doses, especially upon returning from the procedures. For approximately 72 hours, the clients should dispose of urine and feces in special containers and use plastic spoons and forks.
Options B, C, and D: The following clients pose a risk to the pregnant nurse.