A nurse is delegating tasks to assistive personnel. Which of the following should the nurse consider when using one of the five rights of delegation?

Choice A reason: Continuing with the triage process is not an immediate intervention that needs to be taken by the triage nurse, as it may expose more people to the chemical hazard and worsen the situation. The triage nurse should stop the triage process and alert the emergency department staff and management about the potential contamination. The triage nurse should also follow the facility's emergency preparedness plan and protocols for dealing with chemical spills.

Choice B reason: Evacuating the emergency department is an immediate intervention that needs to be taken by the triage nurse, as it helps to protect the safety and health of the staff, clients, and visitors. The triage nurse should assist with evacuating everyone from the emergency department to a safe and designated area, away from the source of contamination. The triage nurse should also ensure that everyone is accounted for and that no one re-enters the emergency department until it is cleared by the authorities.

Choice C reason: Placing the client in a private room is not an immediate intervention that needs to be taken by the triage nurse, as it may not prevent the spread of contamination or provide adequate care to the client. The client who have been exposed to a chemical spill should not be moved to another area of the facility, as they may contaminate other people or surfaces along the way. The client should be kept in a separate and isolated area until they are decontaminated and assessed.

Choice D reason: Treating the client after contaminated items are removed is not an immediate intervention that needs to be taken by the triage nurse, as it may delay or compromise the care of the client. The client who has been exposed to a chemical spill should be treated as soon as possible, as some chemicals can cause serious or irreversible damage to the skin, eyes, lungs, or other organs. The triage nurse should provide basic life support measures, such as airway management, oxygen therapy, or bleeding control while wearing appropriate personal protective equipment (PPE). The triage nurse should also remove any contaminated clothing or jewelry from the client and place them in a sealed bag.

Choice E reason: Sending the client and EMS crew to decontamination is an immediate intervention that needs to be taken by the triage nurse, as it helps to remove or neutralize any harmful chemicals from their skin, hair, or clothing. The triage nurse should direct or escort the client and EMS crew to a designated decontamination area or unit, where they will undergo a thorough washing process with water and soap or other solutions. The triage nurse should also monitor their vital signs and symptoms during and after decontamination.

Choice A reason: Gradual onset of several hours is not a manifestation of a hemorrhagic stroke. A hemorrhagic stroke occurs when a blood vessel in the brain bursts, causing bleeding into the surrounding tissue. This usually happens suddenly and without warning, and can cause rapid deterioration of the client's condition.

Choice B reason: Maintains consciousness is not a manifestation of a hemorrhagic stroke. A hemorrhagic stroke can cause increased intracranial pressure, which can compress the brain and impair its function. This can lead to loss of consciousness, coma, or death.

Choice C reason: Sudden severe headache is a manifestation of a hemorrhagic stroke. A hemorrhagic stroke can cause intense pain in the head, neck, or face, due to the pressure and irritation of the bleeding. The headache may be described as "the worst headache of my life" or "thunderclap headache".

Choice D reason: History of neurologic deficits lasting less than 1 hr. is not a manifestation of a hemorrhagic stroke. This is a characteristic of a transient ischemic attack (TIA), which is also known as a mini-stroke. A TIA occurs when a blood clot temporarily blocks an artery in the brain, causing temporary symptoms such as weakness, numbness, vision loss, or speech difficulty. A TIA does not cause permanent damage to the brain, but it is a warning sign of a possible future stroke.