A facility has been notified of a train derailment resulting in multiple clients experiencing life-threatening injuries. The external disaster plan has been activated. Which of the following actions should a charge nurse on the PACU take?

Take extra wheelchairs to the emergency department.

Send PACU assistive personnel to assist with triage.

Identify stable clients for transfer to a surgical unit.

Report to the command center for further instructions.

Answer and Explanation

The Correct Answer is C

The correct answer is C.

Choice A: Take extra wheelchairs to the emergency department While having extra wheelchairs available can be helpful in a disaster situation, it is not the primary responsibility of the PACU charge nurse. The logistics of equipment distribution would typically be managed by a different team or department.

Choice B: Send PACU assistive personnel to assist with triage Triage is a critical part of disaster response, but it is typically performed by trained emergency department personnel or those with specific training in disaster triage. PACU personnel should focus on their area of expertise, which is post-anesthesia care.

Choice C: Identify stable clients for transfer to a surgical unit This is the correct action. By identifying stable clients for transfer, the PACU charge nurse can free up space for incoming patients who may require immediate post-operative care. This action helps to ensure that the PACU is ready to receive patients who are likely to come from the emergency department after immediate lifesaving interventions.

Choice D: Report to the command center for further instructions While communication with the command center is important in a disaster situation, the PACU charge nurse’s primary responsibility is to manage the care environment and patient flow within their specific unit. Other teams or personnel would likely handle tasks like reporting to the command center.

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Correct Answer is D

Explanation

Answer is: d. "Clients are the experts on their own pain."

Explanation: The charge nurse's response acknowledges the client's self-report of pain, which is considered the most reliable indicator of pain presence and intensity. This approach emphasizes the importance of individualized pain management and respects the client's autonomy.

Statement a. is wrong because the nurse is suggesting an intervention without assessing the client's pain or consulting the healthcare provider. Although nonpharmacological interventions may be appropriate, they should be discussed with the client and provider before making decisions.

Statement b. is wrong because withholding prescribed medication without a valid reason or consultation with the healthcare provider is inappropriate and could result in inadequate pain management.

Statement c. is wrong because contacting mental health services for a consultation based on the assumption that the client is seeking drugs may be premature and overlook the client's reported pain. A thorough assessment and discussion with the healthcare provider should precede any consultation.

A. Set target dates for completion. B. Identify areas of support. C. Determine goals and objectives. D. Implement recommended strategies.

Correct Answer is C

Explanation

Choice A rationale:

Setting target dates for completion is an important step, but it should come after goals and objectives have been established. Goals and objectives provide the foundation for developing a timeline and action plan.

Choice B rationale:

Identifying areas of support is valuable, but it's not the next immediate action after developing the initial plan. Before seeking support, the nurse should clarify the goals and objectives to ensure that the support is aligned with the intended outcomes.

Choice C rationale:

Determining goals and objectives is the next logical step after developing the initial plan. Goals and objectives help guide the committee's work and ensure that the policy revisions are purposeful and aligned with the desired outcomes.

Choice D rationale:

Implementing recommended strategies is a subsequent action that follows the establishment of goals and objectives. Without clear goals and objectives, the strategies might lack direction and cohesiveness.

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A facility has been notified of a train derailment resulting in multiple clients experiencing life-threatening injuries. The external disaster plan has been activated. Which of the following actions should a charge nurse on the PACU take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has back pain presents to an emergency department and is provided a prescription for oxycodone. A staff nurse tells the charge nurse that they think the client is seeking drugs and is not actually in distress. Which of the following responses should the charge nurse make?

Correct Answer is D

Explanation

A charge nurse is leading a committee that is revising the policy for client discharge. After developing the initial plan, which of the following actions should the nurse take next?

Correct Answer is C

Explanation

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