A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first?

Instruct a staff member to maintain a log of emergency care provided.

Apply cervical spine collars to children who have suspected neck trauma.

Notify guardians of the emergency and injuries to their children.

Survey the scene for potential hazards to staff and children.

Answer and Explanation

The Correct Answer is D

A. Instructing a staff member to maintain a log of emergency care provided is not the first action that the nurse should take. This is an important task, but it can be done later, after ensuring the safety of the staff and children and providing immediate care to those who need it.

B. Applying cervical spine collars to children who have suspected neck trauma is not the first action that the nurse should take. This is a priority intervention, but it can only be done after surveying the scene for potential hazards and making sure that it is safe to approach and touch the children.

C. Notifying guardians of the emergency and injuries to their children is not the first action that the nurse should take. This is a necessary step, but it can be delegated to another staff member or done after providing initial care to the children.

D. Surveying the scene for potential hazards to staff and children is the correct answer. This is the first action that the nurse should take, according to the principles of emergency care. The nurse needs to assess the situation and ensure that there are no dangers such as fire, electricity, gas, or falling debris that could harm anyone at the scene. The nurse also needs to determine how many children are injured, how severe their injuries are, and what resources are available to help them.

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Correct Answer is C

Explanation

- A. Incorrect. The nurse should assess the client's IV site every hour to prevent infection and phlebitis.

- B. Incorrect. The nurse should check the client's WBC count every day to monitor for signs of infection or bone marrow suppression.

- C. Correct. The nurse should monitor the client's mouth every 8 hr for signs of oral candidiasis, which is a common fungal infection in immunosuppressed clients.\

- D. Incorrect. The nurse should change the client's IV tubing every 24 hr to reduce the risk of bacterial contamination.

A. Check the client's blood type and crossmatch it against the provider's orders B. Ask the client to state their blood type prior to beginning blood administration C. Compare information on the blood product to the informed consent form D. Verify the client and blood product information with another licensed nurse

Correct Answer is D

Explanation

Verify the client and blood product information with another licensed nurse.

Rationale:

A - This is not a correct procedure for client identification, but rather for blood compatibility. The nurse should check the client's blood type and crossmatch it against the blood product label, not the provider's orders.
B - This is not a reliable method of client identification, as the client may not know or remember their blood type correctly. The nurse should use two identifiers, such as name and date of birth, to confirm the client's identity.
C - This is not a relevant step for client identification, but rather for informed consent. The nurse should ensure that the client has signed an informed consent form before administering blood, but this does not verify that the blood product matches the client.
D - This is the correct procedure for client identification, as it involves two licensed nurses who independently check and confirm the client's identity and the blood product information, such as blood type, Rh factor, expiration date, and serial number.

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A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?

Correct Answer is D

Explanation

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