A nurse is conducting triage of clients transported from a mass casualty incident (MCI). A client arrives saturated with an unknown substance and medical transport reports feeling dizzy. The nurse should prioritize which actions? SELECT ALL THAT APPLY

Assign the client to a private room

Remove client and transport crew from the Emergency department

Contact decontamination team

Call the scene to identify the chemical

Immediately remove the saturated clothing from the client

Answer and Explanation

Correct Answer : B,C,E

Choice A reason:

Assigning the client to a private room is not the priority action in this scenario. The focus should be on decontamination and preventing the spread of the unknown substance to others in the emergency department. Isolation measures can be considered after initial decontamination.

Choice B reason:

Removing the client and transport crew from the Emergency department is a priority action to prevent contamination of the area and exposure to other patients and staff. This step helps contain the potential hazard and ensures the safety of everyone in the department.

Choice C reason:

Contacting the decontamination team is essential for managing the situation. The decontamination team has the expertise and equipment to safely remove the unknown substance from the client and transport crew, reducing the risk of further exposure and contamination.

Choice D reason:

Calling the scene to identify the chemical can be helpful, but it is not the immediate priority. The focus should be on decontamination and ensuring the safety of the client and others. Identifying the chemical can be done concurrently or after initial decontamination efforts.

Choice E reason:

Immediately removing the saturated clothing from the client is a critical step in the decontamination process. Removing contaminated clothing helps reduce the client’s exposure to the substance and prevents further absorption through the skin.

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Correct Answer is B

Explanation

Choice A reason:

Encouraging clients to make decisions without considering their cultural or social background is not aligned with the principles of client-centered care. Understanding and respecting clients’ cultural and social backgrounds are essential for providing holistic and effective care.

Choice B reason:

Ensuring that care plans are tailored to the individual needs and preferences of clients within their community is the cornerstone of client-centered, community-based care. This approach recognizes the unique circumstances of each client and aims to provide personalized care that meets their specific needs and preferences.

Choice C reason:

Focusing primarily on the medical treatment of diseases within a hospital setting is not consistent with community-based care. Community-based care emphasizes providing healthcare services in the community, addressing social determinants of health, and promoting overall well-being outside of hospital settings.

Choice D reason:

Prioritizing the efficiency of healthcare delivery over patient satisfaction and outcomes is contrary to the principles of client-centered care. While efficiency is important, the primary focus should be on achieving positive health outcomes and ensuring patient satisfaction.

A. “It’s not unusual to feel that way at first, but once you learn the routine, you’ll enjoy it.” B. “Diet and exercise are good for you and good for your heart.” C. “Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely.” D. “Your doctor is the expert here, and I’m sure they would only recommend what is best for you.”

Correct Answer is C

Explanation

Choice A reason:

“It’s not unusual to feel that way at first, but once you learn the routine, you’ll enjoy it.” While this response acknowledges the client’s feelings, it does not provide specific information about the benefits of cardiac rehabilitation. The client needs to understand how rehabilitation can help them recover and improve their quality of life.

Choice B reason:

“Diet and exercise are good for you and good for your heart.” This statement is true but too general. It does not address the client’s specific concerns about the purpose and benefits of cardiac rehabilitation. The client needs more detailed information about how the program can help them.

Choice C reason:

“Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely.” This response directly addresses the client’s concerns and provides clear information about the benefits of cardiac rehabilitation. It explains that while the damage cannot be reversed, rehabilitation can help the client regain strength, improve cardiovascular health, and safely return to their daily activities.

Choice D reason:

“Your doctor is the expert here, and I’m sure they would only recommend what is best for you.” While this statement supports the doctor’s recommendation, it does not provide the client with specific information about the benefits of cardiac rehabilitation. The client needs to understand how the program can help them personally.

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A nurse is conducting triage of clients transported from a mass casualty incident (MCI). A client arrives saturated with an unknown substance and medical transport reports feeling dizzy. The nurse should prioritize which actions? SELECT ALL THAT APPLY

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating nursing students on the importance of client-centered community-based care. The nurse understands that which of the following principles is most essential to client-centered, community-based care in nursing?

Correct Answer is B

Explanation

A nurse is caring for a client who questions the need for cardiac rehabilitation, stating, “My heart is permanently damaged from the heart attack, so what’s the point of cardiac rehabilitation?” Which response should the nurse prioritize?

Correct Answer is C

Explanation

A nurse is providing education regarding biologic threats. When discussing anthrax, which of the following should be included as potential portals of entry? SELECT ALL THAT APPLY

An occupational health nurse in the clinic of an industrial plant is developing a guidebook for clinic workers. Which of the following actions should the nurse include as a secondary prevention strategy?

A nurse is caring for a client brought to the Emergency Department as one of the first victims of a train accident. The nurse assesses the client, noting a respiratory rate of 38, a weak, rapid pulse, and uncontrolled bleeding. Using NATO guidelines, the nurse assigns which priority tag?

A nurse is teaching a client who has a new prescription for Sumatriptan (Imitrex) tablets to treat migraine headaches. Which of the following instructions should the nurse include?

A nurse is caring for a client scheduled for a functional assessment who asks, “What is the purpose of this assessment?” How should the nurse most appropriately respond to the client?

A nurse is caring for a client receiving rehabilitation for paralysis following a spinal cord injury and diagnosed with reflex incontinence. Which of the following is the highest priority intervention the nurse should include in the plan of care?

A nursing preceptor is reviewing life expectancy in the twentieth century with a new nurse. The nurse should recognize that which of the following was most responsible for the dramatic increase in life expectancy during the twentieth century?

A nurse is delegating tasks to the assistive personnel (AP). The nurse should direct the AP to complete which of the following tasks first?