A facility has been notified of a train derailment resulting in multiple clients experiencing life-threatening injuries. The external disaster plan has been activated. Which of the following actions should a charge nurse on the PACU take?
Take extra wheelchairs to the emergency department.
Send PACU assistive personnel to assist with triage.
Identify stable clients for transfer to a surgical unit.
Report to the command center for further instructions.
The Correct Answer is C
The correct answer is C.
Choice A: Take extra wheelchairs to the emergency department While having extra wheelchairs available can be helpful in a disaster situation, it is not the primary responsibility of the PACU charge nurse. The logistics of equipment distribution would typically be managed by a different team or department.
Choice B: Send PACU assistive personnel to assist with triage Triage is a critical part of disaster response, but it is typically performed by trained emergency department personnel or those with specific training in disaster triage. PACU personnel should focus on their area of expertise, which is post-anesthesia care.
Choice C: Identify stable clients for transfer to a surgical unit This is the correct action. By identifying stable clients for transfer, the PACU charge nurse can free up space for incoming patients who may require immediate post-operative care. This action helps to ensure that the PACU is ready to receive patients who are likely to come from the emergency department after immediate lifesaving interventions.
Choice D: Report to the command center for further instructions While communication with the command center is important in a disaster situation, the PACU charge nurse’s primary responsibility is to manage the care environment and patient flow within their specific unit. Other teams or personnel would likely handle tasks like reporting to the command center.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A: A nurse is photocopying their assigned client's diagnostic test results.
Choice A rationale: The charge nurse should intervene because photocopying a client's diagnostic test results can pose a potential breach of confidentiality and privacy. Unless there is a specific and authorized reason, personal health information should not be copied or removed from the client's medical record.
Choice B rationale: An assistive personnel (AP) documenting a client's vital signs on the client's paper-based graphic record is a routine task and does not require intervention by the charge nurse.
Choice C rationale: The unit secretary faxing a client's laboratory results to the provider is a standard practice for sharing necessary health information with the care team. No intervention is required.
Choice D rationale: An RN staying with a client who is reading their requested medical records is appropriate. Clients have the right to access their own medical records, and the nurse's presence can help address any questions or concerns the client might have while reviewing their records.
Correct Answer is C
Explanation
The correct answer isChoice C.
Choice A rationale:
Instructing a client on how to take their blood pressure is a task that involves providing education to the client on a non-invasive procedure that they can perform independently. However, this task requires a certain level of knowledge and understanding that an assistive personnel (AP) may not possess. Therefore, it is not the best task to delegate to an AP.
Choice B rationale:
Administering subcutaneous medications to a client is a task that requires a high level of skill and knowledge. It involves understanding the medication, its side effects, and the correct administration technique. This is a task that should be performed by a nurse or a healthcare professional with the appropriate training and licensure. Delegating this task to an AP could potentially put the client’s health at risk.
Choice C rationale:
Determining a client’s intake and output is a task that can be delegated to an AP.This task does not require the use of the nursing process and is within the range of function of an AP. It involves measuring and recording the amount of fluid a client consumes and excretes, which is a task that an AP is capable of performing.
Choice D rationale:
Providing a status update to a client’s family member is a task that requires a high level of discretion and understanding of the client’s condition. It involves communicating sensitive information about the client’s health status, which should be done by a nurse or a healthcare professional with the appropriate training and licensure. Delegating this task to an AP could potentially lead to miscommunication or a breach of the client’s privacy.
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