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?

Assist in discharging stable clients to home.

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

Delegate tasks to emergency health care specialists.

Provide informational updates to members of the media.

None

Answer and Explanation

The Correct Answer is B

The correct answer is: B. Determine the acuity and number of casualties arriving at the facility.

Choice A rationale: Assisting in discharging stable clients to home is important but not the primary focus during the immediate response to a mass casualty event.

Choice B rationale: Determining the acuity and number of casualties arriving at the facility is crucial in a mass casualty event. This involves assessing the severity of injuries and prioritizing care based on urgency, ensuring that the most critical patients receive immediate attention.

Choice C rationale: Delegating tasks to emergency health care specialists is typically the responsibility of team leaders or incident command staff, not the medical-surgical unit nurses.

Choice D rationale: Providing informational updates to members of the media is generally managed by hospital administration or public relations staff, not by medical-surgical nurses.

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Correct Answer is A

Explanation

Choice A rationale:

Elevating the head of the client's bed for 1 hour after the feeding is the correct choice because it helps reduce the risk of aspiration. Elevating the head of the bed at a 30-45 degree angle can promote the flow of enteral feeding solution into the jejunum, reducing the risk of reflux into the stomach and subsequent aspiration.

Choice B rationale:

Administering the feeding solution at a cold temperature is not recommended. Enteral feedings should be given at or near room temperature to prevent discomfort and cramping in the client.

Choice C rationale:

Rotating the jejunostomy tube once per day is not a standard practice. The tube should be secured in place to prevent dislodgement, but routine rotation is not necessary.

Choice D rationale:

Flushing the tube with 90 mL of sterile water before and after the feeding is not necessary for intermittent bolus enteral feedings. Flushing before and after continuous feedings may be required to maintain patency, but for intermittent bolus feedings, it is not a routine practice.

A. Insomnia. B. Low-pitched cry. C. Positive Babinski reflex. D. Bulging fontanel.

Correct Answer is D

Explanation

Choice A rationale:

Insomnia is not typically associated with increased intracranial pressure (ICP) Instead, infants with increased ICP may exhibit signs of altered consciousness, lethargy, or increased sleepiness.

Choice B rationale:

A low-pitched cry is not a specific manifestation of increased ICP. Increased ICP in infants may cause high-pitched crying due to discomfort or irritability.

Choice C rationale:

A positive Babinski reflex is not a typical manifestation of increased ICP in infants. Instead, increased ICP may result in neurological signs such as altered level of consciousness, irritability, vomiting, and changes in vital signs.

Choice D rationale:

Bulging fontanel is the correct manifestation to expect in an infant with increased ICP. The fontanel may become tense and bulging due to increased pressure within the skull. This is a concerning sign and should be promptly reported for further evaluation and intervention.

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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 caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube.Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is collecting data from an 8-month-old infant who has increased intracranial pressure (ICP) Which of the following manifestations should the nurse expect?

Correct Answer is D

Explanation

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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?