Focus on Delegating Prioritizing Triage Disaster

A registered nurse (RN) on the 7 a.m.-3 p.m. shift is planning client assignments for the day. Which clients would be appropriate for the RN to assign to the licensed practical nurse (LPN)? Select all that apply. A. A client who had a mastectomy 2 days ago B. A client with type 1 diabetes mellitus who has a foot ulcer C. A client with left-side weakness who will need assistance with personal care D. A newly admitted client with chronic obstructive pulmonary disease (COPD) E. A client being transferred in from the intensive care unit with a deep vein thrombosis and a heparin drip requiring hourly rate and dose adjustments

A. A client who had a mastectomy 2 days ago B. A client with type 1 diabetes mellitus who has a foot ulcer C. A client with left-side weakness who will need assistance with personal care Rationale: When a nurse delegates aspects of a client's care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. The client with COPD who was admitted during the night will need close monitoring of the respiratory status. An LPN may not administer most high-risk intravenous medications, including heparin. The client who has had a mastectomy and the client with a foot ulcer will likely require dressing changes, an activity that is within the scope of practice of the LPN. The client with left-side weakness requiring personal care assistance could also be assigned to the LPN.

A nurse responds to a disaster call in which a building collapsed and several victims were seriously injured. Which victim will the nurse attend to first? A. A victim with an amputated arm B. A victim with a closed fracture of the leg C. A victim with a sprained ankle and a minor laceration on the head D. A victim with massive head trauma who is in cardiopulmonary arrest

A. A victim with an amputated arm Rationale: A triage system identifies and categorizes victims so that those with the most critical but treatable injuries or illnesses are treated first. In one common system, red denotes priority I, yellow is priority II, green is priority III, and black is priority 0. Priority I includes life-threatening problems that need immediate attention such as trauma, chest pain, respiratory distress, chemicals in the eyes, arm or leg amputation, and shock. Priority II includes victims in need of treatment within 20 minutes to 2 hours — for example, a victim with a simple fracture. Priority III is assigned to victims who can wait for treatment, such as people who have sustained sprains or minor lacerations. Priority 0 denotes a victim who is dying or dead, who has sustained massive head trauma, or who is in cardiopulmonary arrest.

A nurse reviews the laboratory values of a client with bipolar disorder who is taking lithium carbonate (Lithobod) and notes that the serum lithium level is 2.0 mEq/L (2.0 mmol/L). On the basis of this laboratory value, the nurse first: A. Calls the health care provider B. Places the client in the seclusion room C. Administers the prescribed dose of lithium carbonate D. Documents the laboratory report in the client's record

A. Calls the health care provider Rationale: A serum lithium level of 2.0 mEq/L (2.0 mmol/L) indicates toxicity, and the health care provider must be notified. The nurse would assess the client for signs of toxicity, which include coarse hand tremors, persistent gastrointestinal upset, mental confusion, muscle hyperirritability, and incoordination. Administering the prescribed dose of lithium carbonate is incorrect, because the lithium level indicates toxicity. Placing the client in the seclusion room is also inappropriate. Although the laboratory report will be documented in the client's record, this is not the priority action.

A mother brings her child to the emergency department because an insect has flown into the child's ear and the child is complaining of a buzzing sound. The nurse uses a flashlight in an attempt to coax the insect out of the ear, but this intervention is unsuccessful. Which action should the nurse take next? A. Placing diluted alcohol in the ear B. Irrigating the ear with sterile water C. Placing cotton in the ear to stop the buzzing sensation D. Using an otoscope and ear forceps to remove the insect

A. Placing diluted alcohol in the ear Rationale: An insect that makes its way into an ear can often be coaxed out with the use of a flashlight or a humming noise. If this is unsuccessful, the insect must be killed before being removed. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which is then removed with ear forceps. The use of sterile water is avoided, because its use may cause swelling of foreign objects within the ear. Placing cotton in the ear to stop the buzzing and using an otoscope and ear forceps to remove the insect are both incorrect.

A nurse notes that the site of a client's peripheral intravenous (IV) catheter is red and inflamed and feels hard on palpation. On the basis of this assessment, the nurse should first: A. Remove the IV catheter B. Slow the rate of infusion C. Notify the health care provider D. Place warm compresses on the IV site

A. Remove the IV catheter Rationale: Phlebitis at an IV site may be signaled by client discomfort at the site, as well as by redness, warmth, hardness, and swelling proximal to the catheter. The IV catheter should be removed and a new IV catheter inserted at a different site. Recognizing that slowing the infusion will not resolve the client's symptoms will help you eliminate this option. The health care provider would be notified if phlebitis occurred, but this is not the first action for the nurse. Warm compresses are applied to the site to relieve pain and discomfort, but the IV catheter would be removed first.

A client calls the nurse at the emergency department (ED), says that he thinks that he came in contact with poison ivy while working in his yard, and asks the nurse for advice. The nurse tells the client immediately to: A. Take a shower B. Come to the ED C. Soak in a warm oatmeal bath D. Apply hydrocortisone cream to the areas that may have been in contact with the poison ivy

A. Take a shower Rationale: If contact with poison ivy is suspected, symptoms may be averted by immediately rinsing the skin for 15 minutes with running water to remove the resin before it can penetrate the skin. It is not necessary for the client to be seen immediately in the ED. Oatmeal baths are useful in soothing dry or itchy skin. The nurse would not advise the client to apply hydrocortisone cream. Medications should be recommended by the health care provider, and this intervention would probably not be recommended unless a pruritic poison ivy rash actually developed.

A nurse is planning client assignments for the shift. Which clients would the nurse assign to the unlicensed assistive personnel (UAP)? Select all that apply. A. A client receiving blood transfusions B. A client who needs to be ambulated with a walker twice a day C. A client with incontinence who requires a bladder scan after each void D. A client with diabetes mellitus who requires blood glucose testing every 2 hours E. A client on a bowel management program who requires a daily rectal suppository

B. A client who needs to be ambulated with a walker twice a day C. A client with incontinence who requires a bladder scan after each void Rationale: Assignment of tasks must be implemented on the basis of the job description of the UAP, the UAPs level of clinical competence, and state law. A client who is receiving blood transfusions, one in a bowel-management program who requires a rectal suppository daily, and one with diabetes mellitus who requires blood glucose monitoring all require the skill of a licensed nurse, because these are invasive procedures. A client receiving blood must be monitored closely for transfusion reactions. A rectal suppository must be administered by a licensed nurse. Blood glucose monitoring needs to be performed by a licensed nurse. A client with incontinence requiring a bladder scan after each void and a client who needs to be ambulated with a walker twice a day are the most appropriate assignments for the UAP.

A registered nurse (RN) on the night shift has a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP)on the team and is planning the client assignments for the night. Which client does the RN assign to the LPN? Select all that apply. A. A client who undergoing a 24-hour urine collection B. A client with a nasogastric tube who underwent bowel resection 2 days ago C. A client with urinary frequency who needs assistance in getting to the bathroom D. A client scheduled for renal dialysis in the morning who needs assistance with hygiene E. A client who has been fitted with skeletal traction of the right leg after an open reduction measures

B. A client with a nasogastric tube who underwent bowel resection 2 days ago E. A client who has been fitted with skeletal traction of the right leg after an open reduction measures Rationale: When a nurse delegates aspects of a client's care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. An LPN may perform certain invasive procedures. A client with a nasogastric tube who underwent bowel resection 2 days ago and a client in skeletal traction to the right leg after open reduction may safely be assigned to the LPN, because the LPN is capable of performing the nasogastric tube care, dressing changes, and monitoring for postoperative complications that the clients will require. Interventions such as assisting clients with ambulation and hygiene measures and performing noninvasive procedures — the types of tasks identified in the other options — may be assigned to a nursing assistant.

A registered nurse (RN) is planning assignments for six clients on a nursing unit. The RN has an RN, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) on the nursing team. Which clients should the nurse assign to the RN? Select all that apply A. A client who requires tap water enemas until clear B. A client with newly diagnosed type 1 diabetes mellitus C. A client requiring complete assistance with personal care D. A client with gastrointestinal bleeding and a hemoglobin of 7.3 mg/dL (73 g/L) E. A client who was admitted during the night after an acute asthma attack F. A client who has undergone amputation of the right leg amputation and a dressing change

B. A client with newly diagnosed type 1 diabetes mellitus D. A client with gastrointestinal bleeding and a hemoglobin of 7.3 mg/dL (73 g/L) E. A client who was admitted during the night after an acute asthma attack Rationale: When delegating nursing assignments, the nurse must consider the skills and educational level of the nursing staff. The client with newly diagnosed type 1 diabetes mellitus will require significant education, which should be provided by the RN. The client with gastrointestinal bleeding and a low hemoglobin level will likely require a blood transfusion, which must be performed by the RN. The client who was admitted to the hospital during the night after an acute asthma attack would most appropriately be assigned to the RN, because frequent respiratory assessments will be required. The UAP can most appropriately assist with personal care. The LPN can perform dressing changes and administer enemas.

A client is admitted to the emergency department with a complaint of severe crushing chest pain that radiate down both arms. The client is dyspneic, and the nurse immediately places a cannula on the client to deliver oxygen at 4 L/min and inserts an intravenous (IV) catheter. The health care provider orders an immediate troponin determination, a chest x-ray, a 12-lead electrocardiogram (ECG), and morphine sulfate 2 mg IV. What will the nurse do first? A. Obtain a 12-lead ECG B. Administer the IV morphine sulfate Correct C. Call radiology to set up the chest x-ray D. Draw blood for the troponin determination

B. Administer the IV morphine sulfate Rationale: Pain control is a priority, because the chest pain indicates cardiac ischemia. Pain also stimulates the autonomic nervous system and increases preload, resulting in increased myocardial demand and further cardiac damage. The nurse would administer oxygen to the client and administer morphine sulfate. Once the morphine sulfate has been administered, the nurse can obtain the ECG, which may provide evidence of cardiac damage and the location of myocardial ischemia. Although an evaluation of the client's troponin level may be of use in the choice of treatment, this is an assessment, and the situation requires action. Although the chest x-ray might show cardiac enlargement, having the chest x-ray would not influence immediate treatment, so is not the priority.

A client arrives in the emergency department complaining of feeling "something in my eye" and reports that some dust blew into the eye. The nurse would first: A. Apply a patch to the eye B. Assess the client's vision C. Examine the eye, using fluorescein D. Irrigate the eye with sterile normal saline solution

B. Assess the client's vision Rationale: If the client complains of the presence of a foreign body in the eye, the nurse would first assess the client's vision. The nurse would examine the eye with fluorescein if a corneal abrasion is suspected, then perform gentle ocular irrigation with sterile normal saline to remove any particles. Once the foreign body has been removed, an eye patch may be applied.

A nurse on the surgical nursing unit is assessing a postoperative client who is experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg and the pulse rate is 100 beats/min. The client is receiving oxygen at 2 L/min by way of nasal cannula, and the pulse oximetry reading is 92%. Once it has been determined that the airway is patent, what should the nurse do next? A. Notify the surgeon B. Check the client's dressing for bleeding C. Obtain a sample of arterial blood for blood gas results D. Prepare a blood transfusion administration set with normal saline

B. Check the client's dressing for bleeding If this is an option you would pick this as well....Elevate the client's feet and legs above heart level Rationale: The client is exhibiting signs of shock and requires emergency intervention. When shock is suspected, the nurse immediately takes steps to ensure a patent airway and administers oxygen. In this case, the client is already receiving oxygen and the nurse has determined that the airway is patent. The nurse would next elevate the client's feet and legs, keeping his or her head flat or elevated 30 degrees. The nurse should assess the dressing for any bleeding and, if bleeding is noted, apply direct pressure. The surgeon would be notified. The surgeon may prescribe an increase in intravenous fluids or a blood transfusion; however, preparing a transfusion administration set at this time is not indicated.

A client who is receiving a blood transfusion suddenly experiences chills, a high fever, vomiting, and diarrhea and complains of abdominal cramping. The nurse, noting that the client's blood pressure has dropped significantly, suspects that the client is experiencing a bacterial sepsis reaction to the transfusion. The nurse immediately stops the blood transfusion, hangs an intravenous (IV) bag of normal saline solution to be infused at a keep-vein-open rate, and contacts the health care provider, who prescribes several interventions. Which prescription will the nurse implement first? A. Contacting the blood bank B. Obtaining blood for cultures C. Administering the prescribed IV corticosteroid D. Administering the prescribed IV broad-spectrum antibiotic

B. Obtaining blood for cultures Rationale: If bacterial sepsis from a blood transfusion is suspected, the transfusion is stopped and IV access is maintained by infusing normal saline pending further health care provider orders. The nurse would continue to monitor the client's vital signs. Samples for blood culture and Gram staining must be obtained before the administration of medications, particularly the antibiotic. The blood bank is notified, but this is not the first action.

A nurse is providing an orientation to a nurse who will be making assignments to staff and is delegating tasks to the nursing staff. The nurse realizes the education has been successful if the new nurse relates that which tasks are appropriate for the assistive personnel (AP)? Select all that apply. A. Feeding a newly admitted client with dysphagia after a stroke B. Obtaining frequent oral temperatures from a client who is receiving a blood transfusion C. Accompanying a man being discharged home to his transportation at the hospital entrance D. Obtaining a 24-hour dietary recall from a client admitted to the hospital with anorexia nervosa E. Obtaining a clean-catch urine specimen from a client who is complaining of urgency and frequency

B. Obtaining frequent oral temperatures from a client who is receiving a blood transfusion C. Accompanying a man being discharged home to his transportation at the hospital entrance E. Obtaining a clean-catch urine specimen from a client who is complaining of urgency and frequency Rationale: The nurse must determine the most appropriate assignments on the basis of the skills of the staff member and the needs of the client. Although assisting clients with feeding is often within the scope of practice of a AP, a newly admitted client who has had a stroke and is experiencing dysphagia should be cared for by the registered nurse so that an assessment of the client's risk for aspiration may be completed and appropriate recommendations for safe feeding made. Neither would it be appropriate to assign a AP to obtain a 24-hour dietary recall from a client with anorexia nervosa. This assessment is most appropriately conducted by a registered nurse, who would assess the quantity of food consumed by the client. The tasks identified in the remaining three options include no data to indicate that they carry any major risks.

A nurse is delegating tasks to the nursing staff. Which tasks are appropriate for the unlicensed assistive personnel (UAP)? Select all that apply. A. Feeding a newly admitted client with dysphagia after a stroke B. Obtaining frequent oral temperatures from a client who is receiving a blood transfusion C. Accompanying a man being discharged home to his transportation at the hospital entrance D. Obtaining a 24-hour dietary recall from a client admitted to the hospital with anorexia nervosa E. Obtaining a clean-catch urine specimen from a client who is complaining of urgency and frequency

B. Obtaining frequent oral temperatures from a client who is receiving a blood transfusion C. Accompanying a man being discharged home to his transportation at the hospital entrance E. Obtaining a clean-catch urine specimen from a client who is complaining of urgency and frequency Rationale: The nurse must determine the most appropriate assignments on the basis of the skills of the staff member and the needs of the client. Although assisting clients with feeding is often within the scope of practice of a UAP, a newly admitted client who has had a stroke and is experiencing dysphagia should be cared for by the RN so that an assessment of the client's risk for aspiration may be completed and appropriate recommendations for safe feeding made. Neither would it be appropriate to assign a UAP to obtain a 24-hour dietary recall from a client with anorexia nervosa. This assessment is most appropriately conducted by a registered nurse, who would assess the quantity of food consumed by the client. The tasks identified in the remaining three options include no data to indicate that they carry any major risks.

A health care provider places an intestinal tube in a client. After insertion, the nurse immediately: A. Initiates a tube feeding B. Positions the client on the right side C. Secures the tube to the client's face with tape D. Documents the insertion and the client's tolerance of the procedure

B. Positions the client on the right side Rationale: The intestinal tube is a nasoenteric tube that is used to decompress the intestine and correct a bowel obstruction. Initial insertion of the tube is a health care provider's responsibility. The tube, which has a weighted tungsten tip, is advanced either by gravity or manually. Advancement of the tube may be monitored by measuring the tube and by with the use of x-rays. The tube is not secured to the client's face until the desired location is reached. After insertion, the client is positioned on the right side to facilitate passage of the tube via the natural mobility of the gastrointestinal tract. The nurse documents the insertion and the client's tolerance of the procedure in the client's record, but this is not the immediate action.

A client who has sustained an open pneumothorax as a result of a gunshot wound is brought to the emergency department (ED) with an occlusive dressing, placed by a paramedic, over the wound. The ED nurse assesses the client and notes extreme respiratory distress and distended jugular neck veins. On the basis of these assessment findings, the nurse should first: A. Contact the health care provider B. Remove the occlusive dressing C. Assess the client's blood pressure D. Check the client's pulse oximetry readings

B. Remove the occlusive dressing Rationale: Placement of a dressing over a sucking chest wound could convert an open pneumothorax to a closed (tension) pneumothorax, resulting in a sudden decline in respiratory status, mediastinal shift, twisting of the great vessels, and circulatory compromise. If this occurs, the nurse removes the dressing immediately, allowing air to escape. Checking the client's blood pressure and pulse oximetry readings and contacting the health care provider would all be implemented, but none is the first action to be taken.

A client complains of pain at the site of an intravenous (IV) catheter. On assessment, the nurse notes that the site appears bruised and concludes that the client has a hematoma. The nurse first: A. Applies ice to the IV site B. Removes the IV catheter C. Applies pressure to the site D. Notifies the health care provider

B. Removes the IV catheter Rationale: A hematoma at an IV site is a result of leakage of blood into surrounding tissue. It may occur when the back of the vein is pierced during insertion of the catheter. It results in a discolored area of bruising around the IV site and swelling, and the client may complain of pain at the site. The nurse would first remove the IV catheter, then apply pressure. If the hematoma is recent, ice may prevent further seepage into the surrounding tissues. If it did not occur recently, warm, moist compresses will speed reabsorption of the fluid. The nurse should notify the health care provider, but this is not the initial action.

A mother rushes into the emergency department with her child and tells the nurse that the child has drunk bleach from a bottle that the mother was using to clean bathrooms. The nurse notes that child is alert but sees areas of irritation around his mouth. Which intervention does the nurse immediately begin preparing for? A. Insertion of a nasogastric tube B. Administration of syrup of ipecac to induce vomiting C. Dilution of the corrosive substance with water or milk D. Administration of an agent to neutralize the corrosive substance

C. Dilution of the corrosive substance with water or milk Rationale: Household bleach is a corrosive agent. Treatment includes diluting the corrosive agent with water or milk (usually no more than 120 mL). Inducing emesis is contraindicated because vomiting will damage the mucosa. Neutralization is not performed in this type of poisoning because it may result in a hypothermic reaction, which produces heat, causing a worsening of symptoms or producing a thermal burn in addition to a chemical burn. There is no useful purpose for inserting a nasogastric tube in this type of poisoning.

A client arrives at the emergency department after experiencing a traumatic blow to the eye, and a hyphema is diagnosed. The nurse should first: A. Place a patch and shield on the eye B. Administer prescribed cycloplegic eye drops C. Ensure that the client is placed in a semi-Fowler position D. Tell the client that reading and watching television are restricted

C. Ensure that the client is placed in a semi-Fowler position Rationale: Hyphema is the presence of blood in the anterior chamber of the eye. It occurs when force is applied to the eye, breaking the blood vessels. The client is immediately placed on bed rest in a semi-Fowler position to allow gravity to help keep the hyphema away from the optical center of the cornea. Minimal or no sudden eye movements are permitted for 3 to 5 days to decrease the risk of rebleeding. Cycloplegic eye drops may be prescribed to place the eye at rest, and the eye is protected by a patch and shield. Watching television and reading are usually restricted. Hyphema usually resolves in 5 to 7 days.

A client who has been bitten on the right arm by a snake arrives at the emergency department. The nurse immediately: A. Applies ice to the site of the bite B. Prepares to administer tetanus prophylaxis C. Immobilizes the affected arm at heart level D. Places a tourniquet above the site of the bite

C. Immobilizes the affected arm at heart level Rationale: Treatment of snakebite is focused on preventing the spread of venom. Rings, watches, and restrictive clothing should be removed, after which the affected limb should be immobilized at the level of the heart. Ice and tourniquets are not recommended. Tetanus prophylaxis is administered, but this is not the action to be taken first.

A client is complaining of chest pain, and the nurse notes that the client's skin is cool and clammy. The client is receiving oxygen at a rate of 2 L/min, and the pulse oximetry reading is 84%. Which action should the nurse take first? A. Administering nitroglycerin B. Taking the client's vital signs C. Increasing the oxygen to 3 L/min D. Obtaining an arterial blood gas (ABG) specimen

C. Increasing the oxygen to 3 L/min Rationale: Pulse oximetry identifies hemoglobin saturation. A pulse oximetry reading can alert the nurse to desaturation before clinical signs occur. Ideal pulse oximetry values range from 90% to 100%. A range of 85% to 89% is acceptable in certain chronic disease conditions. When the value is below 85%, the body's tissues have a difficult time becoming oxygenated. Therefore the nurse would increase the oxygen to 3 L/min. Although the client is complaining of chest pain, there is no information to indicate that the client is experiencing chest pain that is cardiac in origin, so administering nitroglycerin as the first action is incorrect. Taking the client's vital signs and obtaining an ABG specimen will provide additional data, but in this situation an intervention is needed first.

A nurse is performing closed suctioning through a tracheostomy for a ventilator-dependent client. During the procedure, the alarm on the cardiac monitor sounds and the nurse notes severe bradycardia. The nurse stops suctioning the client and immediately: A. Contacts the respiratory therapist B. Rechecks all ventilator connections C. Oxygenates the client manually with 100% oxygen D. Increases the degree of PEEP the client is receiving

C. Oxygenates the client manually with 100% oxygen Rationale: Suctioning is associated with several complications, including hypoxia, tissue (mucosal) trauma, infection, vagal stimulation, and bronchospasm. Vagal stimulation may result in severe bradycardia, hypotension, heart block, ventricular tachycardia, or asystole. If vagal stimulation occurs, the nurse stops suctioning immediately and oxygenates the client manually with 100% oxygen. Contacting the respiratory therapist will delay the required and immediate intervention. Although regular checks of the ventilator connections are the standard of care for a client undergoing mechanical ventilation, doing so will not alleviate the client's problem in this situation. An increase in PEEP is not indicated at this time.

The nurse is observing a new nurse employee care for a client who has just arrived in the nursing unit after internal maxillary fixation (IMF) surgery. The nurse realizes the new nurse employee understands the priority of care if the new nurse demonstrates which action immediately? A. Administers an antiemetic to prevent vomiting B. Places suction equipment and wire cutters at the bedside C. Positions the client on one side with the head slightly elevated D. Connects the nasogastric (NG) tube to low intermittent suction

C. Positions the client on one side with the head slightly elevated Rationale: Immediately after IMF surgery, the client is positioned on one side with the head slightly elevated. The nurse then connects the NG tube to low intermittent suction to remove fluids and gas from the stomach to help prevent aspiration. Antiemetic medications are administered to prevent vomiting, but this is not the immediate action. Wire cutters and suction equipment should already have been placed at the bedside.

A client with a spinal cord injury suddenly experiences a severe headache and nasal stuffiness. The client is also diaphoretic, hypertensive, and bradycardic. The nurse determines that the client is experiencing autonomic dysreflexia and immediately: A. Notifies the health care provider B. Checks the bladder and catheterizes the client C. Raises the head of the bed to a high Fowler position D. Performs a rectal examination to check for a fecal impaction

C. Raises the head of the bed to a high Fowler position Rationale: Autonomic dysreflexia is an emergency that occurs in people who have sustained spinal injuries as a result of exaggerated autonomic responses to stimuli that are innocuous in normal individuals. It occurs only after spinal shock has resolved. A number of stimuli may trigger this response, including a distended bladder (the most common cause); distension or contraction of the visceral organs, especially the bowel (as a result of constipation or impaction); or stimulation of the skin. When autonomic dysreflexia occurs, the client is immediately placed in a high Fowler position to lower the blood pressure. The health care provider is then notified of the emergency. Finally the nurse performs a rapid assessment to identify and alleviate the cause. The client's bladder is emptied immediately with the use of a urinary catheter, the rectum is checked for the presence of a fecal mass, and the skin is examined for areas of pressure, irritation, or other compromise.

A ventilator's high-pressure alarm sounds. The nurse rushes to the client's room and assesses the client but is unable to determine the cause of the alarm. The nurse immediately: A. Calls the respiratory therapist B. Inserts an oral airway into the client C. Ventilates the client manually with the use of a resuscitation bag D. Silences the alarm and continues trying to determine the cause of the alarm

C. Ventilates the client manually with the use of a resuscitation bag Rationale: Mechanical ventilators have alarm systems that warn the nurse of problems with the client or ventilator. Alarm systems must be activated and functional at all times. The nurse must recognize an emergency and intervene promptly so that complications are prevented. If the cause of an alarm cannot be determined, the nurse ventilates the client manually with the use of a resuscitation bag until the problem is corrected by a second nurse, the respiratory therapist, or the health care provider. Inserting an oral airway is not an immediate intervention, although one may be inserted in a client who is biting on the endotracheal tube.

A nurse has taught the family member of a client undergoing peritoneal dialysis methods to deal with problems with inflow of the dialysate. The nurse realizes the family member understands the provided instructions if the family member mentions taking which action first if there difficulty with installation if the dialysate? A. Repositions the client B. Milks the peritoneal dialysis tube C. Places the client in a supine low Fowler position D. Asks the client about recent problems with constipation

D. Asks the client about recent problems with constipation Rationale: Constipation is the primary cause of problems with inflow and outflow of peritoneal dialysate. Therefore the nurse would first question the client about recent problems with constipation. The nurse would next check the dialysis tubing for kinks and change the client's position. Placing the client in a supine low Fowler position minimizes intraabdominal pressure and promotes adequate inflow and outflow of dialysate. Milking of the peritoneal dialysis tube could dislodge a fibrin clot obstructing the tubing.

A nurse teaches a client with urolithiasis about the signs of urinary obstruction and the interventions to be taken if obstruction is suspected. The nurse tells the client that if signs of urinary obstruction occur, the client should immediately: A. Drink 1500 mL of water B. Check the pH of the urine C. Perform a self-catheterization D. Call the health care provider

D. Call the health care provider Rationale: If signs of urinary obstruction occur, the client should immediately contact the health care provider. Obstruction is a medical emergency, requiring prompt treatment to preserve kidney function. Telling the client to drink 1500 mL of water is incorrect. Additionally, if an obstruction is present, increasing fluids could cause hydronephrosis. Checking the pH of the urine is not related to relieving an obstruction. Self-catheterization is inappropriate and may cause injury to the urethra.

A nurse is monitoring a client with an oral endotracheal tube inserted that is attached to mechanical ventilation. The nurse assesses the client and notes that the client has unequal breath sounds. On the basis of this assessment finding, the nurse would first: A. Suction the endotracheal tube B. Contact the health care provider C. Apply humidified oxygen to the client D. Check the depth marking at the client's lips

D. Check the depth marking at the client's lips Rationale: If it is determined that breath sounds in the client with an endotracheal tube attached to mechanical ventilation are unequal, the nurse would first check the depth marking at the client's lips to evaluate the endotracheal tube for proper depth. If the tube is deeper or shallower than it should be, repositioning of the tube will be necessary. The nurse would then notify the health care provider, who may prescribe a chest x-ray to verify placement and then reposition the tube as needed. If the tube is displaced, suctioning the client would not remedy the problem. Humidified oxygen should already be in place for a client receiving mechanical ventilation.

A nurse notes that a client who has just been given a diagnosis of AIDS appears anxious and is reluctant to ask questions. Which initial action by the nurse is the best way to deal with the observation? A. Allowing the client time to be alone B. Asking a family member to be present when caring for the client C. Asking the client direct questions regarding feelings about having the disease D. Identifying common fears and questions expressed by other clients with the same diagnosis

D. Identifying common fears and questions expressed by other clients with the same diagnosis Rationale: Identifying common fears and questions expressed by other clients often encourages the client to ask questions that he or she has thought of but not verbalized. The nurse should plan to spend additional time with the client. Requesting that a family member be present could reduce the client's anxiety and may be tried after the nurse has talked to the client. However, communication with the client is needed to determine the source of the anxiety. Asking the client direct questions is initially a nontherapeutic communication technique. The client may not be able to explain or discuss his or her feelings about having the disease.

A child arrives at the emergency department experiencing anaphylaxis after being stung by a bee on the right arm. The nurse should first: A. Call a code B. Start an intravenous (IV) line C. Initiate cardiopulmonary resuscitation (CPR) D. Place a tourniquet proximal to the site of the insect sting

D. Place a tourniquet proximal to the site of the insect sting Rationale: Anaphylaxis is a severe immediate hypersensitivity reaction to an excessive release of chemical mediators. Treatment of anaphylaxis must be started immediately, because it may be only a matter of minutes before the child experiences shock. The nurse would immediately take steps to ensure an adequate airway, place a tourniquet just proximal to the site of the insect sting to help confine the allergen, administer epinephrine (medication of choice) as prescribed, administer oxygen, administer corticosteroids and antihistamines as prescribed, keep the child warm and lying flat or with the feet slightly elevated, and start an IV line.

A nurse assesses a client at the beginning of the shift and notes an intravenous (IV) infusion is running at 100 mL/hr and that 800 mL of fluid remains in the IV bag. Thirty minutes later, the client calls the nurse and complains of shortness of breath. The nurse sees that 400 mL of IV solution remains in the IV bag. The nurse immediately: A. Administers oxygen B. Elevates the head of the bed C. Notifies the health care provider D. Stops the rate of the IV infusion

D. Stops the rate of the IV infusion Rationale: The client is most likely experiencing circulatory overload. The nurse may identify the condition by noting that 400 mL has infused over the course of 30 minutes. The first action on the part of the nurse is to stop the rate of the IV infusion but ensure that IV patency is maintained so that any prescribed medications can be administered. Other actions may follow in rapid sequence: The nurse raises the client to an upright position to aid the client's breathing, notifies the health care provider, monitors the client's vital signs, and administers oxygen as prescribed.

A nurse is caring for a client who had a tracheostomy tube inserted 24 hours ago. The client begins to cough vigorously, accidentally decannulating (dislodging) the tube. The nurse immediately takes which action: A. Calls respiratory therapy B. Calls the health care provider C. Replaces the tracheostomy tube D. Ventilates the client with the use of a manual resuscitation bag and face mask

D. Ventilates the client with the use of a manual resuscitation bag and face mask Rationale: Tube dislodgement in the 72 hours after surgery is a medical emergency because the tracheostomy tract has not matured and tissue planes are not well defined. Attempts at replacement of a tube may result in cannulation of subcutaneous tissue planes instead of the trachea itself. Therefore the nurse would ventilate the client with the use of a manual-resuscitation bag and face mask while another nurse calls the resuscitation team for help.