A nurse working on a medical-surgical unit is notified about a mass casualty event that recently took place in the community. Which of the following assignments should the nurse anticipate?

Provide informational updates to members of the media.

Assist in discharging stable clients to home.

Delegate tasks to emergency health care specialists.

Determine the acuity and number of casualties arriving at the facility.

Answer and Explanation

The Correct Answer is B

A. "Provide informational updates to members of the media" is incorrect. This task typically falls under the responsibility of the hospital’s public relations or communications team. Nurses do not usually handle media updates in the context of mass casualty events.

B. "Assist in discharging stable clients to home" is correct. During a mass casualty event, it is important to make room for incoming patients. Discharging stable patients helps free up beds and resources for those who need immediate care.

C. "Delegate tasks to emergency health care specialists" is incorrect. While nurses may delegate some tasks, the nurse’s primary responsibility in this scenario would be managing care within the medical-surgical unit, not directing emergency health care specialists.

D. "Determine the acuity and number of casualties arriving at the facility" is incorrect. This task is generally managed by triage teams or emergency management staff who assess incoming patients at the point of injury or arrival at the facility.

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Correct Answer is D

Explanation

A. "Count the client's respirations for 15 seconds" is incorrect. The nurse should count respirations for a full 60 seconds to ensure accuracy, especially in postoperative clients, as irregularities may be more easily detected with a longer observation period.

B. "Place the client in a supine position" is not necessary. While the position of the client can affect respiration, the nurse does not need to place the client in a supine position specifically to assess respirations. The client should be in a comfortable position that allows for adequate observation.

C. "Inform the client when beginning to observe his respirations" is incorrect. The client should not be aware that their respirations are being counted, as awareness can alter their breathing patterns and lead to inaccurate data.

D. "Observe the movements of the client's chest wall" is correct. Observing the chest wall allows the nurse to assess the rate, depth, and rhythm of respirations, as well as any signs of distress or abnormal patterns, which is crucial for monitoring postoperative respiratory status.

A. Administering a subcutaneous insulin injection B. Removing an NG tube C. Providing discharge teaching about home IV medication therapy D. Collecting a sputum culture

Correct Answer is D

Explanation

A. Administering a subcutaneous insulin injection requires nursing knowledge and skill to ensure correct dosage, technique, and monitoring for side effects. This should not be delegated to an assistive personnel (AP).

B. Removing an NG tube requires nursing assessment to determine if removal is appropriate and safe for the client. It also requires skill in managing complications that may arise. This should not be delegated to an AP.

C. Providing discharge teaching about home IV medication therapy is a complex task that requires nursing knowledge about medication management, potential complications, and instructions for safe administration. It cannot be delegated to an AP.

D. Collecting a sputum culture can be delegated to an AP. This is a task within their scope of practice, provided the AP has been trained in collecting samples and the procedure is straightforward.

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A nurse working on a medical-surgical unit is notified about a mass casualty event that recently took place in the community. Which of the following assignments should the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is postoperative. Which of the following actions should the nurse take when collecting data about the client's respirations?

Correct Answer is D

Explanation

A nurse is planning care for four clients. Which of the following tasks should the nurse ask the charge nurse to reassign to an assistive personnel (AP)?

Correct Answer is D

Explanation

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