A nurse is conducting triage of clients transported from a mass casualty incident (MCI). A client arrives saturated with an unknown substance and medical transport reports feeling dizzy. The nurse should prioritize which actions? SELECT ALL THAT APPLY

Assign the client to a private room

Remove client and transport crew from the Emergency department

Contact decontamination team

Call the scene to identify the chemical

Immediately remove the saturated clothing from the client

Answer and Explanation

Correct Answer : B,C,E

Choice A reason:

Assigning the client to a private room is not the priority action in this scenario. The focus should be on decontamination and preventing the spread of the unknown substance to others in the emergency department. Isolation measures can be considered after initial decontamination.

Choice B reason:

Removing the client and transport crew from the Emergency department is a priority action to prevent contamination of the area and exposure to other patients and staff. This step helps contain the potential hazard and ensures the safety of everyone in the department.

Choice C reason:

Contacting the decontamination team is essential for managing the situation. The decontamination team has the expertise and equipment to safely remove the unknown substance from the client and transport crew, reducing the risk of further exposure and contamination.

Choice D reason:

Calling the scene to identify the chemical can be helpful, but it is not the immediate priority. The focus should be on decontamination and ensuring the safety of the client and others. Identifying the chemical can be done concurrently or after initial decontamination efforts.

Choice E reason:

Immediately removing the saturated clothing from the client is a critical step in the decontamination process. Removing contaminated clothing helps reduce the client’s exposure to the substance and prevents further absorption through the skin.

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Correct Answer is C

Explanation

Choice A reason:

Home care services provide medical and personal care to clients in their homes. While this option may be suitable for clients with less severe symptoms, a client with significant bilateral lower extremities muscle weakness may require more intensive rehabilitation services to improve mobility and function.

Choice B reason:

A sub-acute care facility provides care for clients who need more intensive services than those available in a traditional nursing home but do not require the full resources of a hospital. While this option may be appropriate for some clients, a rehabilitation facility is better suited for addressing the specific needs of a client with significant muscle weakness due to MS.

Choice C reason:

A rehabilitation facility is the most appropriate setting for a client with significant bilateral lower extremities muscle weakness due to MS. These facilities offer specialized programs and therapies designed to improve mobility, strength, and overall function. The client can receive comprehensive care from a multidisciplinary team, including physical therapists, occupational therapists, and neurologists.

Choice D reason:

A skilled nursing facility provides long-term care for clients with chronic conditions or disabilities. While these facilities offer medical care and assistance with daily activities, they may not provide the intensive rehabilitation services needed for a client with significant muscle weakness due to MS.

A. A negative-pressure isolation room B. A private room C. A semi-private room with a client who has pediculosis capitis D. A positive-pressure isolation room

Correct Answer is B

Explanation

Choice A: A negative-pressure isolation room

A negative-pressure isolation room is typically used for patients with airborne infections, such as tuberculosis or measles, to prevent the spread of infectious agents through the air. Scabies, however, is primarily transmitted through direct skin-to-skin contact and occasionally through contact with contaminated clothing or bedding. Therefore, a negative-pressure isolation room is not necessary for a scabies patient1.

Choice B: A private room

A private room is the most appropriate choice for a client with scabies. This type of room helps prevent the spread of the infestation to other patients and allows for better control of the environment. Scabies is highly contagious and can spread through direct contact with the infested person or indirectly through contaminated items. Isolating the patient in a private room minimizes the risk of transmission and allows for proper infection control measures to be implemented2.

Choice C: A semi-private room with a client who has pediculosis capitis

Placing a scabies patient in a semi-private room with another patient, even one with a different parasitic infection like pediculosis capitis (head lice), is not advisable. Both conditions are highly contagious, and cohabitation increases the risk of cross-contamination and further spread of both infestations. Each condition requires specific treatment and isolation protocols to effectively manage and prevent outbreaks3.

Choice D: A positive-pressure isolation room

A positive-pressure isolation room is designed to protect immunocompromised patients from external contaminants by ensuring that air flows out of the room rather than in. This type of room is not suitable for a scabies patient, as it does not address the primary mode of transmission for scabies, which is direct contact. The focus for scabies management should be on preventing direct and indirect contact with others4.

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A nurse is conducting triage of clients transported from a mass casualty incident (MCI). A client arrives saturated with an unknown substance and medical transport reports feeling dizzy. The nurse should prioritize which actions? SELECT ALL THAT APPLY

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is working on discharge planning for a 25-year-old hospitalized client diagnosed with Multiple Sclerosis (MS). The client has significant bilateral lower extremities muscle weakness. Which of the following facilities should the nurse expect this client to be discharged to?

Correct Answer is C

Explanation

A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?

Correct Answer is B

Explanation

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