A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take first?
Instruct the assistive personnel (AP) to focus on clients' activities of daily living (ADLs).
Focus on providing care to clients with life-threatening emergencies.
Initiate discharging stable clients for bed availability
Stock additional unit supplies.
The Correct Answer is B
B. In a disaster situation, prioritizing care for clients with life-threatening emergencies is crucial to ensure that those in the most critical condition receive immediate attention. This aligns with triage principles and ensures that limited resources are used effectively.
A. While addressing ADLs is important, it is secondary to addressing life-threatening emergencies in a disaster scenario.
C. Discharging stable clients can help increase bed availability but should be considered after addressing immediate life-threatening needs.
D. Stocking additional supplies is necessary but should follow after ensuring that life-threatening conditions are managed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. The fingerstick blood glucose level of 55 mg/dL at 1130 indicates hypoglycemia, which requires immediate attention to prevent further complications such as loss of consciousness or severe symptoms.
B. The client's report of shakiness, hunger, and cool, diaphoretic skin are signs of hypoglycemia, especially given the low blood glucose level. This requires prompt intervention to manage the blood glucose level.
C. The temperature of 37.8 °C (100 °F) is slightly elevated but does not require immediate follow-up unless there are other symptoms of infection or significant changes.
D. The elevated heart rate of 118/min could indicate an underlying issue such as dehydration, hypoglycemia, or infection. It requires further evaluation in the context of other findings.
E. The SpO2 of 95% on room air is within an acceptable range and does not require immediate follow-up unless there are other signs of respiratory distress or worsening condition.
F. The HbA1c of 8.01% reflects long-term glucose control but is not an immediate concern for follow-up in the acute setting. It is important for overall management but not an urgent issue for this particular scenario.
Correct Answer is ["11.074"]
Explanation
To calculate the infusion rate, we'll use the following formula:
Infusion rate (mL/hr) = Desired dose (units/hr) / Concentration of heparin (units/mL)
First, calculate the desired dose in units/hr:
- 14 units/kg/hr x 79.1 kg = 1107.4 units/hr
Next, calculate the concentration of heparin in the IV bag:
- 25,000 units / 250 mL = 100 units/mL
Finally, plug the values into the formula:
- Infusion rate = 1107.4 units/hr / 100 units/mL = 11.074 mL/hr
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