A nurse is assisting with the care of a group of clients during a mass casualty event. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Respond to family members about a client's condition.

Determine which clients should be seen first.

Clean and dress client abdominal wounds.

Take vital signs on clients as they are admitted.

Answer and Explanation

The Correct Answer is D

Choice A reason: Responding to family requires clinical judgment and communication skills beyond AP scope. Nurses handle this in mass casualty for accuracy.

Choice B reason: Triage prioritization needs nursing assessment skills, not AP training. Determining care order is a licensed responsibility in emergencies like this.

Choice C reason: Cleaning and dressing wounds involves sterile technique and assessment, outside AP scope. Nurses perform this in mass casualty settings.

Choice D reason: Taking vital signs is within AP scope, providing data for nurse triage. It’s a routine task, safely assigned in a mass casualty event.

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Correct Answer is C

Explanation

Choice A reason: Brewed green tea has 25-40 mg caffeine per 8 oz, from tea leaves’ natural stimulants. It exceeds cocoa, making it a higher-caffeine choice.

Choice B reason: Cola soft drinks contain 30-50 mg caffeine per 8 oz, added artificially. This surpasses cocoa’s level, placing it higher in caffeine content.

Choice C reason: Hot cocoa has 5-15 mg caffeine per 8 oz, naturally low from cocoa beans. It’s the least caffeinated option among these beverages.

Choice D reason: Instant coffee delivers 60-100 mg caffeine per 8 oz, concentrated from coffee grounds. It’s far higher than cocoa, unsuitable for reduction.

A. Measure the duration of the seizure B. Restrain the client’s arms and legs to prevent injury C. Lower the side rails of the bed when the seizure begins D. Insert an oral airway into the client’s mouth

Correct Answer is A

Explanation

Choice A reason: Measuring seizure duration is critical for medical management, as prolonged seizures (over 5 minutes) may require emergency intervention like anticonvulsants. Timing helps assess severity and guides treatment, prioritizing safety and data collection over unnecessary restraint, aligning with evidence-based practice.

Choice B reason: Restraining arms and legs during a seizure risks injury like fractures or dislocations, as tonic-clonic movements are involuntary and forceful. Safety involves clearing the area, not restricting motion, since restraint opposes neurological protocols, increasing harm rather than protecting the client.

Choice C reason: Lowering side rails during a seizure increases fall risk, as tonic-clonic activity can propel the client off the bed. Keeping rails up, padded if possible, ensures safety by containing movement, contradicting this action’s utility, as evidence prioritizes preventing trauma.

Choice D reason: Inserting an oral airway during a seizure is dangerous; clenched jaws can break teeth or the device, risking aspiration. Airway management occurs post-seizure if needed, not during, as neurological guidelines emphasize protection without invasive actions causing injury.

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A nurse is assisting with the care of a group of clients during a mass casualty event. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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