A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The unlicensed assistive personnel (UAP) working on a general medical unit ask the charge nurse what they should do first. Which instructions should the charge nurse provide to the UAPS?

Go to the emergency department and complete assigned tasks.

Shut all doors to client rooms on the unit in case a fire erupts.

Tell all their assigned clients to stay in their rooms.

Offer to assist in the intensive care unit with clients ventilator-dependent.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Go to the emergency department and complete assigned tasks: UAPs should remain on their assigned units unless directed otherwise by leadership. Relocating without orders could compromise continuity and safety in their current area.

B. Shut all doors to client rooms on the unit in case a fire erupts: There is no immediate threat of fire. This may increase client anxiety or hinder necessary observation in a power outage. Fire protocols are separate from internal disaster procedures unless a fire is confirmed.

C. Tell all their assigned clients to stay in their rooms: This maintains order and safety during a chaotic event. It prevents unnecessary movement in darkened or unfamiliar areas and reduces the risk of injury in the absence of full power.

D. Offer to assist in the intensive care unit with clients ventilator-dependent: UAPs are not qualified to assist with critical care clients, especially ventilator-dependent ones. They should remain within their competency and scope of practice.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Rationale:

Count the respirations: Lorazepam is a benzodiazepine that can cause respiratory depression, especially when given IV. Regular monitoring of respiratory rate helps detect hypoventilation early.
Listen for heart palpitations: While the client initially had atrial tachycardia, monitoring palpitations is not a priority in evaluating lorazepam’s effectiveness, which focuses more on CNS and respiratory status.
Assess for constipation: Constipation is not an acute or common side effect associated with single-dose IV lorazepam. It is not relevant in short-term monitoring.
Evaluate client for motor coordination: Benzodiazepines like lorazepam may impair psychomotor function. Assessing coordination can help monitor CNS depressant effects and safety.
Observe level of consciousness: Altered LOC is a common side effect of lorazepam due to its sedative properties. Ongoing neurological checks are essential.
Monitor for drowsiness: Drowsiness is a common and expected effect of lorazepam. Monitoring helps determine if the sedative effect is appropriate or excessive.

A. Plan for a follow-up echocardiogram occurring in 4 to 6 weeks. B. Resume the toddler's normal immunization schedule. C. Irritability and tinnitus are expected for up to 2 weeks. D. Manage joint pain with a nonsteroidal antiinflammatory.

Correct Answer is A

Explanation

Rationale:
A. Plan for a follow-up echocardiogram occurring in 4 to 6 weeks: Follow-up echocardiograms are standard to monitor for coronary artery aneurysms, which may develop even after treatment. Early detection is vital to prevent long-term cardiac complications.

B. Resume the toddler's normal immunization schedule: Live vaccines such as MMR and varicella should be delayed for at least 10 months after IVIG, as the therapy can interfere with vaccine efficacy. Non-live vaccines may proceed as scheduled.

C. Irritability and tinnitus are expected for up to 2 weeks: Irritability is common, but tinnitus is not a recognized symptom of Kawasaki disease or its treatment. Persistent symptoms should be reported rather than assumed to be expected.

D. Manage joint pain with a nonsteroidal antiinflammatory: Aspirin, not general NSAIDs, is typically used for inflammation and thrombosis prevention in Kawasaki disease. Use of other NSAIDs may interfere with aspirin’s antiplatelet effects.

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits For each action, identify if it is indicated or not indicated when monitoring the effects of lorazepam administration. Each row must have one response action selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

The nurse caring for a toddler with Kawasaki disease who is receiving intravenous immunoglobulin for severe coronary inflammation is planning discharge teaching for the parents. Which instruction should the nurse provide during the discharge education?

Correct Answer is A

Explanation

An adolescent with autism spectrum disorder (ASD) comes to the clinic for the first time. Which intervention(s) should the nurse implement? Select all that apply.

The nurse is assigned to care for a client diagnosed with psoriasis. Which behavior by the nurse addresses this client's psychosocial need for acceptance?

A group of nurses implement a pilot study to evaluate a proposed evidence-based change to providing client care. Evaluation indicates successful outcomes and the nurses want to integrate the change throughout the facility. Which actions should be taken? Select all that apply.

The nurse is assessing a client who is experiencing overwhelming anxiety and difficulty performing self-care. Which question should the nurse ask first?

The healthcare provider prescribes 500 mL of 0.45% normal saline with 100 units regular insulin to infuse at 15 units/hour. The drop factor is 20 gtt/mL. The nurse should regulate the IV to deliver how many gtt/minute? (Enter numerical value only.)

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide?

The nurse is caring for a client with left-sided hemiparesis after a stroke. Which action should the nurse take to safely assist the client with ambulation?

Which dietary intervention(s) should the nurse include in the plan of care for a client who had bariatric surgery? Select all that apply.