AH 4--Emergency Response and Security Plans
The nurse is teaching a class about preventing infant abduction to pregnant clients. What statement(s) by the clients would indicate that the teaching was successful? *Select all that apply.* a) "I should avoid posting birth announcements in my yard or on social media." b) "I should not allow my infant to leave the room without me." c) "I should question anyone in my room who I have not been introduced to." d) "I should only allow people to enter my home who state they are from the hospital." e) "I should call the nurse if I see anything suspicious on the unit."
*a) "I should avoid posting birth announcements in my yard or on social media."* *c) "I should question anyone in my room who I have not been introduced to."* *e) "I should call the nurse if I see anything suspicious on the unit."* *Rationale: Education should be provided to expectant birth parents about preventing infant abductions. Best practices include calling the nurse if they see something suspicious or if someone who has not been introduced to them comes into their hospital room. They should also avoid posting birth announcements in their yards or on social media as this could alert potential abductors of the presence of an infant in the home. It will sometimes be necessary for the infant to leave the room without their birth parent; however, only authorized staff who have been introduced to the birth parent should do that. The parent(s) should also be taught to check the credentials of anyone who states they are from the hospital or home health after discharge.
A nurse is providing a tour of the labor and birth unit to a group of parents who will soon be welcoming their newborns. When the nurse is questioned by a couple concerning the risk of kidnapping a newborn, which response(s) should the nurse provide? *Select all that apply.* A) The staff will obtain a footprint of the newborn and a fingerprint of the birthing parent before they leave the birthing unit. b) Family members will have to sign in to enter the unit and sign out when they leave. c) The newborn and parents will be given matching identification bands. d) Prevention training is mandatory for parents and staff. e) The staff will attach an electronic alarm device to the newborn's leg.
*A) The staff will obtain a footprint of the newborn and a fingerprint of the birthing parent before they leave the birthing unit.* *c) The newborn and parents will be given matching identification bands.* *d) Prevention training is mandatory for parents and staff.* *e.) The staff will attach an electronic alarm device to the newborn's leg.* *Rationale: Prevention of kidnapping of newborns can include various techniques, such as obtaining a footprint of the newborn and a fingerprint of the birth parent before they leave the birthing unit; attaching an electronic alarm device to either the newborn's leg or umbilical cord; providing matching identification bands for the parents and newborn; and providing prevention training for the parents and staff. Requiring family members to sign in and out when visiting the unit is not a normal protocol used to prevent newborn kidnapping.*
The nurse notices some new electrical equipment has been brought to the operating suite. Which action should the nurse prioritize when preparing to use this new equipment?
*Check that a safety label has been applied* *Rationale: The biomedical or engineering department should test and approve electrical devices that are used in medical facilities, especially in operative suites as the risk for fire is elevated due to the various chemicals and substances used during surgery. A safety label should be applied by the biomedical or engineering department to verify the equipment has been checked and determined to be safe to use, and the nurse should check if this department has applied a safety label before using it. The nurse should not need to plug it in to check its functioning as this has already been accomplished by the biomedical or engineering department. Checking the client's records and disinfecting the equipment would be handled after verifying a safety label is present.
The parent of a newborn infant on the postpartum unit has called out to the nurse in great distress, stating, "My baby is missing!" What is the nurse's best initial response?
*Immediately secure the postpartum unit and match the identification bands of all infants to birth parents.* *Rationale: If an infant abduction is reported or suspected, the nurse should immediately and simultaneously search the entire unit and call facility security, another designated authority, or both according to the facility's critical incident-response plan. This initial search should precede calling the authorities. If warranted, an internal code may be called, but this is normally a code pink. The nurse should question the parent about the details preceding the alleged abduction, but doing so should not delay the initiation of a search. Activation of the hospital's lockdown procedure is implemented in situations where there is imminent danger to the clients and staff.
A client from a correctional facility is admitted to the hospital wearing handcuffs. The nurse caring for the client needs to provide morning care and notices the two correctional officers socializing with the nursing staff at the desk. What is the best action by the nurse in this situation?
*Insist that the officers stay in the room at all times* *Rationale: A correctional officer should be with the client at all times. To protect the safety of the nurse and the client, the nurse should refuse to administer care without an officer present. The other options put the nurse and the client at risk.
The psychiatric nurse notes that a client has a gun in their backpack. The client has not threatened anyone or tried to take out the gun and is not aware that the nurse has seen the gun. What action should the nurse take?
*Notify the supervisor outside of the clients room* *Rationale: The nurse should not approach a client in possession of a gun. Instead, they should notify a supervisor, who should then notify the police department immediately. Only a trained police officer should try to take a gun away from a person or negotiate with a person about surrendering a gun.
An emergency department nurse is triaging clients involved in a bridge collapse. The nurse notes that a client is not breathing and has no pulse. What should the nurse do immediately?
*Obtain an external defibrillator* *Rationale: When triaging clients, if breathing is absent or the client is only gasping and the nurse does not feel a pulse within 10 seconds, the nurse should have a coworker retrieve the defibrillator and start cardiopulmonary resuscitation. The client needs immediate care, but the nurse should initiate care rather than tagging the client. The client may need hypothermia protocols and a neurological assessment, but the nurse first needs to address the client's lack of a pulse with cardiopulmonary resuscitation.
After a local factory explodes, a nurse begins to triage the victims. Victim 1 is initially unconscious and not breathing. After the victim's airway is opened, the victim resumes spontaneous respirations at a rate of 18 and has a capillary refill time of less than 2 seconds, but remains unconscious. What color tag should the nurse use for this victim? a) red b) yellow c) black d) green
*a) red* *Rationale: According to the SMART (Simple Triage And Rapid Treatment) method, the nurse should use a *red tag* for this client. The red tag is for clients who require immediate medical attention to survive. Although indicators of the client's respiration and circulation status are within normal range, the client's mental status is compromised, and further treatment may be needed to prevent death. *A yellow tag* is given when the client has serious, potentially life-threatening injuries that would be treated immediately if there were capacity to do so but the client can likely survive without immediate treatment. Because this client is unconscious, the client's condition may not be stable enough to warrant a yellow tag and the associated delay in treatment. *A green tag* is given for relatively minor injuries whose status is unlikely to deteriorate; the client may be able to engage in self-care, and the injuries can wait until more serious injuries are cared for. *Black tags* are given to deceased victims and to clients who are unlikely to survive due to the severity of their injuries and the level of available care. Palliative care should be provided to clients with black tags.
A staff nurse receives a phone call and is told there is a bomb in a client's room. What is the nurse's priority action? a)Put the call on hold and find the charge nurse. b) Ask the caller for details about the bomb placement. c) Transfer the call to security. d) Signal to staff to close the client's doors.
*b) Ask the caller for details about the bomb placement.* *rationale: With imminent danger, it is important to determine as much information as possible, as quickly as possible. Transferring the call, or placing the caller on hold could result in a disconnection and loss of information. Clients may need to be evacuated
A nurse working in the operating room smells smoke during a procedure, and a colleague reports that a small fire has broken out on the other side of the operating suite. Which action should the nurse take first? a) Retrieve the fire extinguisher and extinguish the fire. b) Assist with moving the client's bed to the hallway. c) Pull the fire alarm on the wall. d) Walk to the site of the fire to confirm the colleague's report.
*b) Assist with moving the clients bed to the hallway* *Rationale: Following the RACE acronym, the nurse's priority is to rescue anyone who is in danger during a fire. The second step would be to activate the alarm by pulling the wall alarm and notifying emergency services using the facility protocol. Extinguishing the fire would be the last step and should only be attempted if the fire is small. The nurse would not want to walk to the site of the fire to obtain visual confirmation before acting as this could put the nurse in danger and delay the correct actions.
A group of people arrives at the emergency department reporting extreme periorbital swelling, cough, shortness of breath, and tightness in the throat. They report that someone threw a bomb that exploded at their feet. What is the best action by the nurse? a) Remove the clients' clothes. b) Take them to the decontamination area. c) Administer NAAK (Nerve Agent Antidote Kit). d) Administer 2 liters of oxygen.
*b) Take them to the decontamination area.* *Rationale: The best action by the nurse is to take the clients to the decontamination area to be decontaminated. That way the agent is no longer infiltrating the clients nor are the other individuals in the emergency room exposed to the decontaminating agent. Once decontamination is completed, then other actions can be administered such as administering oxygen and/or NAAK. But the first priority is to stop the decontaminating agent from continuing to impact the victims by completing decontamination.
A nurse is receiving the hand-off information for a client who is transferring from the postanesthesia care unit (PACU) to the inpatient surgical unit. Which comment should prompt the receiving nurse to ask for more clarification? a) "They were not happy they had to use a bedpan." b) "They do not want to take too much pain medication." c) "They get very upset when I touch them sometimes." d) "They were a little slow waking up but seem to be okay now."
*c) "They get very upset when I touch them sometimes."* *Rationale: The hand-off communication should include information about the client's behavior. Telling the new staff the client gets upset when a staff member touches them should raise red flags about potential violent behavior and should be investigated further so the staff can be prepared to handle the situation appropriately. The other responses give the nurse specific information about this client but do not necessarily indicate potential violent behavior.
A nurse is conducting an in-service program for staff who prepare and administer hazardous drugs. The nurse is focusing on safety measures to be followed in case of a spill. The nurse determines that additional teaching is needed based on which statement made by the group? a) "We need to check the safety data sheet to see if a chemical deactivator is needed." b) "The facility's spill kit should have the necessary supplies to clean up the spill." c) "We should clean from the most contaminated area to the least contaminated area." d) "It's important to wash any skin that directly contacts the drug with soap and water."
*c) "We should clean from the most contaminated area to the least contaminated area."*
The nurse is providing care for a client who is scheduled for a requested surgical procedure. The nurse walks into the client's room during an argument between the client and a family member who is against the procedure. The family member threatens to drag the client out of the room. What action should the nurse take first? a) Ask the client what they want to do. b) Lock the doors on the unit. c) Call for assistance. d) Try to talk with the family member.
*c) Call for assistance* *Rationale: The nurse should call for assistance and report the situation immediately as per the facility's policies. This type of behavior would be considered verbal abuse, and if the family member does physically remove the client, it then escalates to physical abuse. After calling for assistance, the nurse would then use methods to de-escalate the situation and prevent violence. This could include talking to the family member and trying to understand what is happening. It could also include locking unused doors as appropriate to areas such as staff and treatment rooms. The nurse could ask the client if they have changed their mind about continuing with the procedure as part of the discussion with the family member.
The client has returned to the surgery unit from the postanesthesia care unit (PACU). The client's respirations are rapid and shallow, their pulse is 120 bpm, and their blood pressure is 88/52 mm Hg. The client's level of consciousness is declining. What should the nurse do first? a) Call the health care provider (HCP). b) Call the PACU. c) Call the rapid response team (RRT)/medical emergency team. d) Call the respiratory therapist.
*c) Call the rapid response team (RRT/medical emergency team) *Rationale: The nurse should first call the RRT or the medical emergency team that provides a team approach to evaluate and treat immediately clients with alterations in vital signs or neurologic deterioration. The client's vital signs have changed since the client was in the PACU, and immediate action is required to manage the changes; the staff in PACU are not responsible for managing care once the client is transferred to the surgical unit. The respiratory therapist may be a part of the RRT but should not be called first.
A client has been brought to the emergency department after spilling hydrofluoric acid on their hand and forearm. When assessing for consequent electrolyte imbalances that accompany the client's injury, the nurse should prioritize what assessment? a) cognition b) fluid balance c) cardiac monitoring d) pain assessment
*c) Cardiac Monitoring* *Rationale: Even when very small surface areas are involved, hydrofluoric acid burns can cause hypocalcemia and hypomagnesemia, which can produce fatal arrhythmia. For this reason, vigilant assessment of cardiac status is a priority. Pain assessment will be necessary but poses a lesser threat to the client's survival. Similarly, cognitive assessment and assessment of fluid balance are necessary but do not relate as directly to the client's most immediate threat to survival.
As the nursing supervisor walks past a client's room, they hear a family member berate and threaten the nurse if they do not change what they are doing to provide care for the client. The nurse apologizes and tries to explain what they are doing, but the family member only becomes more aggressive and hostile. What action should the nursing supervisor take first? a) Complete proper documentation for the sentinel event. b) Call security to escort the family member out of the facility. c) Inform the family member this is verbal abuse and must stop. d) Ask the nurse why they never reported this behavior.
*c) Inform the family member this is verbal abuse and must stop.* *Rationale: Ensuring that smoke detectors are in working order is critical to fire safety. In addition, electrical appliances, such as heating pads, should be in good condition and functioning properly, with cords not positioned under carpets or rugs. Space heaters are a common cause of fires and should be at least 3 feet (0.9 meters) away from anything flammable, such as curtains, bedding, and furniture. Assistive devices (such as mobility aids, eyeglasses, and hearing aids), a flashlight, a telephone, and emergency numbers should be within reach at all times, should the need for escape be necessary.
A client who was discharged earlier in the day returns to the nursing unit and demands acetaminophen with codeine. The client is advised that the client is no longer being treated on the unit and this medication cannot be administered. The client states, "I know where you park your cars, and you'd better watch out when you leave here tonight." What is the next step that the nurse should take? a) Ask the client to discuss the matter privately. b) Call the nursing supervisor. c) Call the police. d) Notify the client's family.
*c) call the police* *Rationale: The nurse should call the police because threatening staff is a criminal act. Nursing supervisors are not able to take the same actions as police officers to protect the staff. Asking to meet with the client privately is unsafe; the client's behavior is unpredictable, and the client could be a risk to others or self. Calling the client's family is not appropriate given the threats uttered.
The nurse enters a child's room to administer medications and notices that the child is missing. The nurse cannot find the child in the immediate area, including the playroom. Who does the nurse notify first? a) other unit nurses b) the client's parent or guardian c) hospital security d) local law enforcement
*c) hospital security* *Rationale: In the case of a potential child abduction in the hospital, the nurse should notify the hospital security team. The security team notifies local law enforcement. Once the abduction is confirmed by law enforcement, the parents should be notified. Privacy laws should be followed, so the media should not be alerted by the care team.
The perioperative nurse is participating in open reduction and internal fixation (ORIF) of a client's femoral fracture when a fire breaks out near the anesthesia station. Place the actions involved in implementing the RACE steps of fire response into the correct sequence. All options must be used. Promptly wheel the client out of the operating room. Activate the fire alarm system. Enclose the fire to limit spread. Attempt to put out the fire, if it is safe to do so.
1.) Promptly wheel the client out of the operating room. 2.) Activate the fire alarm system. 3.) Enclose the fire to limit spread. 4.) Attempt to put out the fire, if it is safe to do so. *rationale: The RACE steps are: R: Rescue the client by removing the client or the source of the fire (wheel the client out of the operating room). A: Activate the alarm. C: Confine the fire (enclose the fire to limit spread). E: Evacuate or extinguish, as appropriate, the fire (put out the fire if it is safe to do so).
The nurse notices a fire in a wastebasket in a client's room. In which order of priority from first to last should the nurse perform the actions? All options must be used. -Remove the client from the room. -Confine the fire by closing the door to the client's room. -Pull the fire alarm at the alarm pull station. -Extinguish the fire
1.) Remove the client from the room. 2.) Pull the fire alarm at the alarm pull station. 3.) Confine the fire by closing the door to the client's room. 4.) Extinguish the fire *Rationale: The nurse uses the RACE procedure to manage a fire: Rescue, Alarm, Confine, Extinguish.
The nurse discovers a fire in a storage closet in the hallway of a hospital unit. Place in order the steps the nurse should take for client safety. All options must be used. -Activate the Alarm. -Evacuate the unit. -Rescue clients. -Contain the fire.
1.) Rescue clients. 2.) Activate the alarm. 3.) Contain the fire. 4.) Evacuate the unit. *Rationale: If the nurse finds a fire, the nurse will follow the steps in RACE: rescue clients, activate alarm, contain the fire, and evacuate the unit. This sequence is established in facilities for client safety.
Several clients have been brought to the emergency department (ED) following a bus accident. The ED nurse is performing across-the-room assessments to make initial determinations about triaging clients. The nurse should include what parameter(s) in these assessments? *Select all that apply.* a) self-reported pain rating b) level of consciousness c) ambulation ability d) ability to speak and tone of voice e) skin color and condition
b) level of consciousness c) ambulation ability d) ability to speak and tone of voice e) skin color and condition *rationale: Across-the-room assessment involves a visual scan for obvious indicators of distress. Assessment parameters would include clients' skin color and condition, their ability to ambulate, their general level of consciousness, and their ability to speak. Pain assessment, including rating, is an important component of triage assessment, but it is not achievable during an across-the-room assessment that focuses on readily observable objective data.
A high school student is brought to the nurse by the chemistry instructor after a classmate accidentally spilled a toxic chemical on the student's hands. Which action should the school nurse prioritize in this situation? a) Run water at low pressure over the hands to remove the chemical. b) Use a neutralizing agent to decrease the effects of the chemical. c) Have the client soak their hands in a basin of warm water. d) Use cold water to remove the chemical from the hands.
*a) Run water at low pressure over the hands to remove the chemical* *Rationale: The nurse should use copious amounts of lukewarm water at a low pressure to dilute the chemical and avoid driving the chemical deeper into the tissues. Ice or cold water would not be used because these could cause hypothermia. The chemical should be removed, not deactivated by a neutralizing agent.
The nurse is assisting a community to develop primary prevention strategies for its disaster management plan. What action should the nurse recommend? *Select all that apply.* a) developing a resource map b) creating a risk map c) triaging victims to nearest hospital d) planning an evacuation route e) restoring power during the emergency
*a) developing a resource map* *b) creating a risk map* *d) planning an evacuation route* *Rationale: Creation of a risk map and resource map as well as the determination of lines of authority are all appropriate primary prevention strategies. Planning an evacuation route is also a primary prevention strategy. Restoration of power after an outage during an emergency is a secondary prevention strategy. Triaging victims is also a secondary prevention strategy.
The nurse is working in an emergency department (ED) in a city that is experiencing an outbreak of Ebola virus disease. A client came into the ED with a history of fever, nausea, vomiting, and diarrhea. The client died before a diagnosis of Ebola was confirmed through laboratory testing. What personal protective equipment (PPE) should the nurse use to perform postmortem care on the client? *Select all that apply.* a) gloves b) gown c) face mask d) lead-lined vest e) heavy-duty utility gloves
*a) gloves* *b) gown* *c) face mask* *Rationale: A client with Ebola virus disease may be contagious even after death, so standard, contact, and droplet precautions should be used for postmortem care. The nurse should wear a mask, gown, and gloves. A lead-lined vest is not necessary as the client does not have any radioactive properties. Heavy-duty utility gloves are not necessary as these are used to prevent cuts from broken glass.
The occupational health nurse who provides care at a large industrial facility has just been informed that a worker has sustained chemical burns. Following an immediate assessment of the client's airway, breathing, and circulation, the nurse should prioritize which action? a) identifying the specific offending substance involved b) applying personal protective equipment (PPE) to the injured worker c) removing the chemical from the worker's skin using sterile gauze d) assessing and treating the client's pain
*a) identifying the specific substance involved* *Rationale: In any case of chemical burns, it is an immediate priority to gather details of the chemical that caused the injuries. This information will inform subsequent treatment, which normally involves thorough rinsing (not physical removal), though exceptions exist. Pain control is a high priority, but stopping the burning is the immediate action. The nurse must take action to prevent cross-contamination, but this does not require the application of PPE to the client.
The nurse in the emergency department instructs staff and first responders on immediate emergency care for burns. Which statement(s) by the nurse indicate(s) teaching was effective? *Select all that apply.* a) "It can take as long as 20 minutes to effectively cool down a burn area." b) "Remove clothing that is sticking to a burned area to stop the burning." c) "Flood the burned area with cool water to stop the burning effect." d) "Jewelry should be removed from the client as it can be a source of heat." e)"Put out flames by wrapping the person in a covering to smother them."
*a) "It can take as long as 20 minutes to effectively cool down a burn area."* *c) "Flood the burned area with cool water to stop the burning effect."* *d) "Jewelry should be removed from the client as it can be a source of heat."* *e)"Put out flames by wrapping the person in a covering to smother them."* *Rationale: Teaching about immediate burn care begins by communicating that if a person is on fire, they should be told to drop to the ground, cover their face, and roll to put out the flames. (If the person panics and runs, air will fuel the flames, worsening the burn and increasing the risk for inhalation injury.) Alternatively, the person can be wrapped in a blanket or other large covering to smother the flames and protect the burned area from dirt. The burned area can be cooled with cool flowing water to decrease pain and stop the burn from growing deeper and larger. The ideal water temperature for cooling is 59°F (15°C) with an acceptable range of 46.4°F to 77°F (8°C to 25°C) for 20 minutes. If possible, potential sources of heat, such as jewelry, belt buckles, and some types of clothing, responders should be removed. In addition to adding to the burning process, these items can cause constriction as edema develops. If the person's clothing adheres to the skin, the clothing should be cut and not removed.
A nurse making a home visit to an older adult client with limited mobility is reviewing home fire safety measures with the client and spouse. The client currently sleeps in a first-floor bedroom and uses a walker to ambulate. After teaching the client and spouse about these measures, the nurse determines that the teaching was successful based on which statement? a) "We'll have a family member change the batteries in our smoke detectors when they come by this week." b) "I'll make sure my walker is near the front door at night so I have it if I need to get out quickly." c) "I'll move the space heater closer to my bed so I don't have to keep the temperature so high." d) "We will make sure that the cord to the heating pad is under the throw rug so I don't trip over it."
*a) "We'll have a family member change the batteries in our smoke detectors when they come by this week."* *Rationale: Ensuring that smoke detectors are in working order is critical to fire safety. In addition, electrical appliances, such as heating pads, should be in good condition and functioning properly, with cords not positioned under carpets or rugs. Space heaters are a common cause of fires and should be at least 3 feet (0.9 meters) away from anything flammable, such as curtains, bedding, and furniture. Assistive devices (such as mobility aids, eyeglasses, and hearing aids), a flashlight, a telephone, and emergency numbers should be within reach at all times, should the need for escape be necessary.
A client has made multiple inappropriate sexual comments to several of the nurses and unlicensed assistive personnel (UAP) in the acute care unit. The charge nurse, accompanied by a colleague, goes into the room to address the behavior. What intervention by the charge nurse would be appropriate for this client? a) Have the client sign a written contract that states they will avoid sexually provocative behaviors. b) Allow only male staff members to care for the client. c) Assign 24-hour continuous monitoring by a technician. d) Place a bed alarm on the client's bed, and have restraints available.
*a) Have the client sign a written contract that states they will avoid sexually provocative behaviors.* *Rationale: Clients exhibiting sexually provocative behaviors tend to view sexuality as a means to an end. They use sexuality to gain favoritism; however, their behavior may also be connected to impulsiveness or certain medical disorders. They may also participate in sexual behaviors to escape emotional or physical pain or deal with stress. It is important to establish professional boundaries with a client exhibiting this type of behavior. One way to do that is to develop a verbal or written contract with the client that outlines the consequences of sexually provocative or otherwise inappropriate behaviors. The client should sign the contract to indicate understanding. It is not appropriate to have 24-hour monitoring or a bed alarm or restraints because these do not address the client's sexual behavior and may put staff at greater risk. Having an all-male care team is not appropriate and may not be feasible, especially if the client has acute care needs that require immediate intervention.
A nurse is scheduled to perform an initial home visit to a new client who is beginning home intravenous therapy. As the nurse is getting out of the car and beginning to approach the client's building, a group of people begin following and jeering at the nurse. Which is the nurse's best response to this situation? a) Leave the area in the car, provided the nurse can get to it safely. b) Perform the home visit and ensure that the group is gone before leaving. c) Call out to attract attention from bystanders. d) Confront the group of people in an assertive but non-aggressive manner.
*a) Leave the area in the car, provided the nurse can get to it safely* *Rationale: The nurse's safety is paramount, and the nurse's best response to a perceived threat when performing a home visit is to remove themself from the situation, provided this can be achieved without incurring further risk.
A nurse is walking down the hall in the main corridor of a hospital when the infant security alert system sounds and a code for an infant abduction is announced. The first responsibility of the nurse when this situation occurs is to take which action? a) Observe individuals in the area for large bags or oversized coats. b) Call the nursery to ask which baby is missing. c) Move to the entrance of the hospital and check each person leaving. d) Go to the obstetrics unit to determine if they need help with the situation.
*a) Observe individuals in the area for large bags or oversized coats.* *Rationale: The process for infant abduction in a hospital system focuses on utilizing all health care workers to observe for anyone who may possibly be concealing an infant in a large bag or under an oversized coat and is attempting to leave the building. Moving to the entrances and exits and checking each individual would be the responsibility of the doorman or security staff within the hospital system. Going to the obstetrics unit to determine if they need help would not be advised as the doors to the unit will be locked and access will not be available. Calling the nursery to ask about a missing baby wastes time, and the nursery staff should not reveal such information.
The nurse is developing a community disaster plan for the safety of children in an underrepresented community. Which information should the nurse apply when creating a plan of care for a disaster involving a chemical attack? a) The overall fluid reserve volume of children is less than that of adults, making children less susceptible to the effects of a chemical. b) Children are less susceptible to the effects of a chemical attack because they breathe at a faster rate than adults. c) Children are more susceptible to the effects of a chemical attack as they have a smaller body surface area in relation to weight than adults. d) Children have fewer fat deposits under the skin, resulting in thinner skin and causing children to be more susceptible to the effects of a chemical.
*d) Children have fewer fat deposits under the skin, resulting in thinner skin and causing children to be more susceptible to the effects of a chemical.* *Rationale: Children are more susceptible to the effects of chemical and biological attacks because they have thinner skin than adults due to fewer fat deposits, increasing their risk for absorbing a chemical. Children also have a larger, not smaller, body surface area in relation to their weight than adults, which increases the chance of chemical absorption. Children breathe at a faster, not slower, rate than adults, allowing them to inhale greater amounts of a toxic agent. Additionally, some chemical agents are heavier than air and accumulate close to the ground, which is closer to a child's breathing zone than an adult's. Because children have less fluid reserve than adults, children are at greater risk for developing rapid dehydration from agents that cause vomiting or diarrhea, making them more susceptible than adults.
The nurse is providing care for a toddler and notes the parents come at separate times and do not interact, but if they do come at the same time, they begin to fight and yell at each other. Each parent insists that the nurse should only listen to their requests and not the other parent's. The nurse then learns the couple is going through a divorce and fighting each other for full custody of the toddler. Which response should the nurse prioritize? a) Document each interaction in the toddler's health record. b) Encourage the parents to meet with each other to develop the care plan for the toddler. c) File a report with the local law enforcement agency and Child Protective Services (CPS). d) Ensure appropriate security measures are in place to protect the toddler.
*d) Ensure appropriate security measures are in place to protect the toddler." *Rationale: The safety of the toddler is the highest priority at this point to protect against violence and possible abduction. Children who are at a high risk for abduction require additional security measures to prevent abduction from happening. After the nurse ensures security measures are in place, the situation should then be appropriately documented. Insisting that the parents meet would be inappropriate and most likely nonproductive. Filing a report with the local law enforcement agency or CPS would be the responsibility of the security department of the facility if the toddler is abducted or the situation advances to verbal or physical abuse against the toddler or health care staff. The staff should always follow the facility's policies in these types of situations.
The circulating nurse is assisting in a laser-assisted in situ keratomileusis (LASIK) procedure. What piece of safety equipment should the nurse prioritize in this case? a) utility gloves b) sharps container c) lead apron d) fire extinguisher
*d) Fire extinguisher* *Rationale: Lasers represent a significant risk for fires during a procedure. If the circulating nurse is aware that a laser will be used in a surgical procedure, they should prioritize having a fire extinguisher in the room. Sharps containers may be needed for the procedure, but they are not associated with lasers. Utility gloves and lead aprons are not needed for laser procedures. Remediation:
The nurse is making an initial visit to the home of a client. Which action(s) should the nurse take to ensure for personal safety? *Select all that apply.* a) Park in a well-lighted area. b) Telephone the client when arriving at the front door. c) Keep the car windows rolled up with doors locked when driving. d) Become familiar with the client's neighborhood. e) Lock personal items in the trunk of the car.
a) Park in a well-lighted area. c) Keep the car windows rolled up with doors locked when driving. d) Become familiar with the client's neighborhood. e) Lock personal items in the trunk of the car. *Rationale: To ensure for personal safety when making a home visit, the nurse should become familiar with the client's neighborhood, keep the car windows rolled up and doors locked when driving, park in a well-lighted area, and lock personal items in the trunk of the car. The nurse should call the client before leaving the car, not when arriving at the front door.
