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. The two clients who can share a room are the pregnant client and the client with a broken arm and facial lacerations because these clients are stable. The other clients in answers A needs to be placed in separate rooms because the schizophrenic will further upset the client with an ulcerative colitis. Answer C is incorrect because this child is terminal and he should not be placed in the room with the client with a frontal head injury. Answer D is incorrect because the chest pain may be related to a myocardial infarction.
The nurse is making rounds. Which client should be seen first?
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Solution
Answer D is correct. The client with multiple sclerosis should receive priority because of the IV cortisone treatment. This client is at highest risk for complications. The clients in answers A and B are more stable and are not the priority. The client with MRSA (methicillin-resistant staphylococcus aureus) is being treated with antibiotics, but there is no data to indicate that the nurse should see this client first, so answer C is incorrect.
The nurse is suspected of charting the administration of a medication that he did not give. After talking to the nurse, the charge nurse should:
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Solution
Answer B is correct. After discussing with the nurse and documenting the incident, filing a formal reprimand is the first action for the charge nurse to take. If the nurse continues following an incorrect procedure that causes, or could cause, harm to the client, termination might be needed. The Joint Commission on Accreditation of Hospitals will probably be interested in the actions in answers A and C, but this is not the immediate action to take. The failure of the nursing assistant to care for the client with hepatitis might result in termination, but this is not of interest to the Joint Commission; therefore, answer D is incorrect.
Which information should be reported to the state Board of Nursing?
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Solution
Answer B is correct. An inaccurate narcotic count on the unit should be reported to the state Board of Nursing because narcotics are controlled substances. Answers A, C, and D are incorrect because they are of little concern to the state board. Although they are important functions, these actions would be resolved within the hospital.
Which nurse should be assigned to care for the postpartal client with preeclampsia? The nurse with:
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Solution
Answer B is correct. The nurse in answer B has the most experience in knowing possible complications involving preeclampsia. The nurse in answer A is a new nurse to the unit and so should not be assigned to this client; the nurses in answers C and D have no experience with the postpartum client, so neither should be assigned to this 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
Answer B is correct. The vital signs are abnormal and should be reported to the doctor immediately. To continue to monitor the vital signs, as in answer A, could result in deterioration of the client’s condition. Asking the client how he feels in answer C will provide only subjective data. The nurse in answer D is not the best nurse to assign because this client is unstable.
Which assignment should not be performed by the licensed practical nurse?
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Solution
Answer D is correct. The licensed practical nurse should not be assigned to begin a blood transfusion. The licensed practical nurse can insert a Foley catheter, as stated in answer A; discontinue a nasogastric tube, as stated in answer B; and collect sputum specimen, as stated in answer C. Thus, answers A, B, and C are all incorrect.
The nurse caring for a client on the pediatric 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
Answer D is correct. Malpractice is failing to perform or performing an act that causes harm to the client, making answer D correct. In answer A, negligence is failing to perform care for the client. In answer B, a tort is a wrongful act committed to the client or his belongings. Answer C is incorrect because assault is willfully hitting or restraining the client.
Which client should be assigned to a private room if only one is available?
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Solution
Answer A is correct. The client with Cushing’s syndrome has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immune suppressed, and he should not have a roommate because of the possibility of infection. In answer B, the client with diabetes poses no risk to other clients. The client in answer C has an increase in growth hormone and poses no risk to himself or others. The client in answer D has hyperthyroidism or myxedema and so poses no risk to others or himself.
Which client should be assigned to the pregnant licensed practical nurse?
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Solution
Answer A is correct. The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy in answer A travels to the radium department for therapy; thus, the radiation stays in the department. The client himself is not radioactive. The client in answer B poses a risk to the pregnant client because the implant stays with the patient. The client in answer C is radioactive in very small doses. For approximately 72 hours, the client should dispose of urine and feces in special containers and use plastic spoons and forks. The client in answer D is also radioactive in small amounts, especially upon return from the procedure. Thus, answers B, C, and D are all incorrect.