A nurse working in an assisted living facility has been made aware that a chemical disaster has occurred within the community and is a threat to the facility. Which of the following actions should the nurse take? (select all that apply)

Turn off fans and heaters.

Evacuate the entire facility of all residents and staff.

Close the doors and windows of each resident’s apartment.

Be sure the fireplaces in each room are burning.

Place wet towels under the doors.

Answer and Explanation

Correct Answer : A,C,E

A.   Turning off fans and heaters can help prevent the circulation of potentially contaminated air.
B.   Evacuation may be necessary in extreme cases but should be done following established protocols and considering the safety of residents.
C.   Closing doors and windows helps minimize the entry of external air, reducing exposure to potential contaminants.
D.   Keeping fireplaces burning may increase the risk of indoor air pollution and is not a recommended action during a chemical disaster.
E.   Placing wet towels under doors can help create a barrier to limit the entry of external air and contaminants.

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Correct Answer is ["B","C","G","H"]

Explanation

A. Providing oxygen at 6 L/min via nasal cannula is not indicated based on the information provided. The client denies shortness of breath, and vital signs are within normal limits.
B. Applying cold compresses to joints can help reduce swelling and alleviate pain in the extremities.
C. Performing passive range of motion (ROM) exercises is appropriate to maintain joint flexibility and prevent contractures.
D. Administering IV fluids is not explicitly indicated based on the information provided. Fluid management should be individualized based on the client's condition and underlying factors.
E. Obtaining consent for a blood transfusion is not necessary unless the client has severe anemia or bleeding.
F. Restricting fluid intake to 1,400 mL/day may cause dehydration and electrolyte imbalance.
G. Administering meperidine (a narcotic analgesic) may be considered for pain relief.
H. Encouraging bedrest is appropriate to minimize joint stress and promote healing, especially when there is pain and swelling in the extremities.

A. Instruct the client on use of call light. B. Apply an ambulation alarm to the client’s leg. C. Apply restraints to the client PRN. D. Raise the four side rails of the client’s bed. E. Check on the client hourly

Correct Answer is ["A","B","D","E"]

Explanation

A. Instructing the client on the use of the call light allows them to easily summon assistance when needed.
B. Applying an ambulation alarm helps monitor the client's movement, especially if there is a risk of falls or wandering.

C. Applying restraints is not the first-line intervention and should only be used when less restrictive measures are ineffective, and the client is at risk of harm to themselves or others.
D. Raising the four side rails of the client’s bed is a safety measure to prevent falls and ensure the client's protection.

E. Checking on the client hourly is an essential intervention to monitor the client’s mental status and ensure safety. Frequent assessments allow for early identification of complications related to opioid use, such as respiratory depression or increased sedation.

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A nurse working in an assisted living facility has been made aware that a chemical disaster has occurred within the community and is a threat to the facility. Which of the following actions should the nurse take? (select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for an adolescent client. Exhibits Which of the following actions should the nurse identify as part of the plan of care? Select all that apply.

Correct Answer is ["B","C","G","H"]

Explanation

A nurse is caring for a client who has a prescription for scheduled opioid analgesia and notes a change in the client’s mental status. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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