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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Checking the IV site for bleeding is important but should be done more frequently in a client with thrombocytopenia (low platelet count), as bleeding can occur unexpectedly.
B. Administering stool softeners is a key intervention for clients with thrombocytopenia, as it helps to prevent straining during bowel movements, which could cause rectal bleeding due to fragile blood vessels.
C. Checking for proteinuria is not directly related to thrombocytopenia or the risk of bleeding. It is more commonly associated with kidney function monitoring.
D. Obtaining body temperature readings is important for infection monitoring, but it does not directly address the risk associated with a low platelet count, which primarily concerns bleeding.

A. Decrease the client's oral fluid intake. B. Weigh the client every evening. C. Monitor the client's urine output every 6 hrs. D. Remind the client he might feel a constant urge to void.

Correct Answer is D

Explanation

A. Decreasing the client's oral fluid intake is inappropriate in the postoperative period following a TURP, as adequate hydration is essential to prevent clot formation and maintain catheter patency. Limiting fluids could lead to increased clot formation and obstructed flow.
B. Weighing the client every evening is not a relevant intervention in the immediate postoperative period of TURP. Weight monitoring is more critical for fluid balance in chronic conditions such as heart failure or renal disease, not in the acute setting after TURP.
C. Monitoring urine output every 6 hours is insufficient for a client receiving continuous bladder irrigation. Immediate postoperative care requires more frequent monitoring to detect potential complications such as clot retention or hemorrhage.
D. Reminding the client that he might feel a constant urge to void is essential. Continuous bladder irrigation can cause bladder spasms and a persistent sensation of needing to urinate, which is common after TURP. This helps the client understand and cope with these sensations, reducing anxiety and unnecessary concern.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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