A nurse is working on a facility's postpartum unit. For which of the following situations should the nurse initiate a security alert?
An employee is using a basinet to move a newborn from the nursery to the mother's room.
An individual is wearing an identification badge without a photograph.
A parent requests that an individual who plans to perform tests on their newborn be identified.
A newborn in a client's room is missing one of its identification bands.
The Correct Answer is D
A. An employee is using a bassinet to move a newborn from the nursery to the mother's room: Transporting a newborn in a bassinet within the unit is standard practice and does not indicate a security breach. Employees are trained to move infants safely between nursery and mother’s room as part of routine care.
B. An individual is wearing an identification badge without a photograph: While a photo badge is important for verifying identity, encountering someone without a photo badge does not immediately indicate a security threat. The nurse should verify the individual’s credentials, but it does not warrant activating a facility-wide security alert.
C. A parent requests that an individual who plans to perform tests on their newborn be identified: This situation involves parental verification of personnel, which is part of routine patient rights and safety practices. It does not represent a security breach requiring an alert, but staff should provide appropriate identification and explanations.
D. A newborn in a client's room is missing one of its identification bands: Missing identification bands on a newborn is a serious safety concern and indicates a potential risk for misidentification or abduction. This situation requires immediate initiation of a security alert according to hospital policy to protect the infant and notify appropriate security personnel.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Air is heard escaping from around the mask: Escaping air indicates a poor seal, which compromises the delivery of high-concentration oxygen. A properly functioning non-rebreather mask should have a snug fit to the face, minimizing leaks and ensuring the client receives the intended oxygen concentration.
B. The flow control meter dial is at the correct setting: While setting the prescribed flow rate is necessary, the flow meter alone does not confirm that the mask or reservoir is functioning properly. The actual delivery of oxygen to the client depends on correct assembly, reservoir inflation, and mask seal.
C. The attached reservoir bag is inflated: An inflated reservoir bag indicates that oxygen is flowing into the bag and that the client will receive near 100% oxygen during inspiration. Proper inflation confirms that the one-way valves are functioning and that the mask is delivering high-concentration oxygen as intended.
D. The exhalation ports are covered during inspiration and expiration: Exhalation ports on a non-rebreather mask should remain open to allow carbon dioxide to escape while one-way valves prevent room air from entering during inspiration. Covered ports would restrict gas exchange and compromise oxygen delivery, indicating malfunction.
Correct Answer is A
Explanation
A. The client's blood pressure has been reduced: Morphine is an opioid agonist that relieves pain by binding to mu receptors in the central nervous system, thereby decreasing transmission and perception of nociceptive stimuli. Relief of postoperative pain reduces sympathetic nervous system activation and catecholamine release, which can lower blood pressure toward baseline.
B. The client exhibits diaphoresis: Diaphoresis is commonly associated with unrelieved pain due to increased sympathetic stimulation and stress hormone release. It may also occur with anxiety, hypoglycemia, or opioid withdrawal, but it is not a desired therapeutic outcome of morphine administration.
C. The client is grimacing: Grimacing is a classic nonverbal indicator of pain and ongoing nociceptive stimulation. Effective opioid analgesia should decrease observable pain behaviors such as facial tension, guarding, or restlessness. Continued grimacing indicates that the medication has not sufficiently reduced the client’s pain perception.
D. The client has an elevated heart rate: Tachycardia is a physiologic response to pain, anxiety, or hypovolemia, mediated by sympathetic nervous system activation. Adequate morphine administration should decrease sympathetic output by relieving pain, which typically lowers heart rate toward baseline.
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