A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to care for first?
A client requesting a referral for home health services
A client asking about his PCA pump that contains morphine
A client who needs assistance with a bath
A client who has questions about his new prescription
The Correct Answer is B
Rationale:
A. Requesting a referral is important but not immediately critical compared to other needs.
B. Asking about a PCA pump with morphine indicates a potential issue with pain management or medication delivery that needs immediate attention.
C. Assisting with a bath is important for comfort and hygiene but is less urgent compared to immediate pain management.
D. Questions about a new prescription should be addressed but are generally less urgent than issues related to pain management.
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Correct Answer is B
Explanation
Rationale:
A. Dilated pupils are typically associated with stimulant use, not opioids.
B. Euphoria is a common effect of opioid use and can indicate misuse or diversion of these medications.
C. Rhinorrhea is usually associated with withdrawal from opioids rather than their use.
D. Hallucinations can occur with certain drugs but are less commonly associated with opioid use compared to euphoria.
Correct Answer is ["A","D","E"]
Explanation
Rationale:
A. While pulling the fire alarm is correct, removing the client from the room without following the full RACE sequence (Remove, Alarm, Confine, Extinguish/Evacuate) is incorrect. The immediate safety measures should include ensuring that the alarm is activated before evacuation and confining the fire if possible.
B. Verifying the order of protective equipment removal with the nurse shows a good practice and adherence to proper infection control procedures.
C. Washing hands prior to leaving the room after disinfecting equipment indicates proper infection control practice.
D. Handwashing is a crucial aspect of infection control. Failure to perform hand hygiene during or after patient care increases the risk of infection transmission. Immediate follow-up is needed to ensure that proper hand hygiene practices are adhered to.
E. Knowing the locations of alarms is vital for effective fire safety. Inability to identify these locations indicates a significant gap in preparedness for emergencies. Immediate follow-up is necessary to ensure that staff are familiar with fire safety procedures and equipment locations.
F. Successfully completing the skills in simulation, including emptying the client's trash can, shows adherence to task requirements but is not a critical issue requiring immediate follow-up compared to the other findings.