EAQ

A registered nurse is teaching a student nurse about the various stages of infections. Which statement made by the student nurse indicates a need for additional teaching? - "The incubation period for mumps is 1 to 5 days." - "The acute symptoms of malaria will disappear during the convalescence stage." - "Group A beta-hemolytic Streptococcus causes a sore throat, pain, and swelling at the illness stage." - "Herpes simplex at the prodromal stage begins with itching at the site before the lesion appears."

"The incubation period for mumps is 1 to 5 days." *The average incubation period for mumps is 16 to 18 days, but can range from 12-25 days.

In a health care setting, the restraint order for a patient is renewed every hour. What is the likely age of the patient?

6 years

After reviewing the laboratory reports of a patient, the nurse suspects that the patient has an acute suppurative infection. What would be the patient's neutrophil count? - 60% - 65% - 70% - 75%

75%

The nurse's admission assessment section includes .....

A summary of the patient's nursing history and physical examination.

Which safety precaution performed by a parent lowers the risk of sudden infant death syndrome (SIDS) in a 1-year-old child?

Having the child sleep on their back or side

Which suggestion would be appropriate to prevent unilateral neglect in a patient with hemiparesis?

Hemiparesis is a condition in which there is weakness on one side of the body. A patient with unilateral neglect related to brain injury will benefit from touching the left side of the body frequently with the right hand.

Which care intervention would reduce the risk of sudden infant death syndrome (SIDS)?

Immunizing the infant

Which restraint is banned due to the risk of fatal injuries?

Jacket restraint

After performing a prescrub wash, a nurse dries his or her hands and forearms with a paper towel. What is the rationale behind this action?

Promoting a reduction in microorganisms

Which microorganism is associated with an exogenous infection? Staphylococci Enterococci Streptococci Salmonella

Salmonella

Which part of a sterile gown is actually considered sterile? Collar of the gown Area below the waist Underside of the sleeves Anterior surface of the sleeves

The anterior surface of the sleeves is considered sterile. The collar of the gown, the area below the waist, and the underside of the sleeves are not considered as sterile.

Which risk factor causes secondary infections? - Trauma - Heredity - Nutrition - Chronic disease

Trauma *Physical trauma may cause fractures and internal bleeding, which may lead to secondary infections. Heredity causes diseases, such as sickle cell disease, diabetes resulting in anemia, and delayed healing. Poor nutrition causes obesity and anorexia, resulting in an impaired immune response. Chronic disease causes chronic obstructive pulmonary disease, heart failure, diabetes resulting in pneumonia, skin breakdown, and venous stasis ulcers.

Which statement regarding vascular and cellular responses is true? - Vasodilation occurs at the site of injury. - Chronic inflammation is an immediate response to cellular injury. - Increased blood flow leads to coldness at the site of inflammation. - The cellular response involves red blood cells at the site of infection.

Vasodilation occurs at the site of injury resulting in excessive blood loss at the site.

A primary healthcare provider calls the nursing unit and requests the nurse on duty to update a patient's chart with the physician orders provided. What actions does the nurse perform?

When a member from the healthcare team is not physically present to update the chart, the nurse can update the chart upon request. While doing so, the nurse carefully documents the date and time of entry of the information, the source of the information, and the mode of communication, (such as a telephone call).

A registered nurse teaches a nursing student about cleaning instruments before sterilization. Which statement made by the nursing student needs correction? - "I will use a brush to wash the objects." - "I will wash the objects with warm water." - "I will dry the objects before disinfection." - "I will rinse the contaminated objects in hot water."

"I will rinse the contaminated objects in hot water." *Contaminated objects should be rinsed with cold water. Hot water should not be used because it causes the protein in organic material to coagulate and stick to objects, which makes removal difficult. The nurse should use a brush to remove dirt or material in grooves or seams. The nurse should wash objects with soap and warm water. Objects should be dried before disinfection or sterilization.

A licensed practical nurse is preparing to assist in a sterile procedure. Which nursing action is appropriate in surgical hand asepsis? - Scrubbing the hands for 5 minutes - Washing over the rings and watch - Keeping the hands and arms below the elbows - Allowing the water to flow from the elbows to the hands

* While performing surgical hand asepsis, the nurse should scrub the hands for 5 minutes to eliminate transient microorganisms and reduce resident hand flora. During a sterilizing procedure, the nurse should remove all jewelry and accessories, such watches and rings. The hands should be above the elbows while performing a surgical scrub.

A registered nurse teaches a nursing student about precautions to be taken while pouring a sterile solution. Which statement made by the nursing student indicates a need for correction? Select all that apply. - "I should quickly pour the contents into the container." - "I should pour fluids into the plastic molded sections." - "I should verify the contents and expiration date." - "I should remove the sterile seal and cap from the bottle in an upward motion." - "I should make sure that a receptacle for a solution is located far away from the sterile work surface edge."

- "I should quickly pour the contents into the container." - "I should make sure that a receptacle for a solution is located far away from the sterile work surface edge." *The nurse should slowly pour the contents to prevent splashing. The nurse should make sure that the receptacle for the solution is located near or on a sterile work surface edge to prevent reaching over the sterile field. The contents should be poured into cups or plastic molded sections in sterile kits. The nurse should verify the contents and expiration date of the solution to ensure that the solution is viable. The nurse should remove the sterile seal and cap from the bottle in an upward motion to prevent contamination of the bottle lip.

A registered nurse evaluates a nursing student after teaching the nursing skills required during sterilization disinfection and cleaning of equipment. Which statements made by the nursing student indicates a need for further teaching? Select all that apply. - "Implants are considered noncritical items and must be disinfected." - "Stethoscopes are considered noncritical items and must be disinfected." - "Surgical instruments are considered critical items and must be sterilized." - "Endotracheal tubes are considered semi-critical items and must be sterilized." - "Urinary catheters are considered semi-critical items and must be disinfected."

- "Implants are considered noncritical items and must be disinfected." - "Urinary catheters are considered semi-critical items and must be disinfected

A patient who underwent bariatric surgery complains of serous exudate at the site of surgery. The primary health care provider diagnoses the patient with a health care-associated infection. Which microorganisms can cause exogenous infections? Select all that apply. - Yeast - Aspergillus - Streptococcus - Staphylococcus - Clostridium tetani

- Aspergillus - Clostridium tetani

Which precautions should the nurse follow while performing surgical asepsis? - Rearranging the linen after a sterile object becomes exposed - Holding the item close to the sterile field by touching the sterile surface - Avoiding touching the sterile tip to the surface of a clean disposable glove - Discarding objects immediately when stored sterile packages become wet - Opening sterile packages when a minimum number of people are walking into an area

- Avoiding touching the sterile tip to the surface of a clean disposable glove - Discarding objects immediately when stored sterile packages become wet - Opening sterile packages when a minimum number of people are walking into an area *The nurse should avoid activities such as excessive movements or rearranging linens after a sterile object or field becomes exposed. While opening sterile packages, the nurse should hold the item closely to the sterile field without touching the sterile surface. Touching the sterile tip to the clean disposable glove leads to contamination. The nurse should discard objects immediately or send equipment for resterilization when sterile items become wet. Sterile packages should be opened when a minimum number of people are walking in an area to prevent contamination of the package.

Which nursing actions are examples of following precautions to eliminate reservoirs of infection? Select all that apply. - Changing soiled dressings - Emptying urinary drainage bags every 4 hours - Covering the mouth and nose when coughing or sneezing - Instructing the patient to maintain adequate fluid intake - Wearing disposable gloves while making contact with patients

- Changing soiled dressings - Emptying urinary drainage bags every 4 hours - Instructing the patient to maintain adequate fluid intake *The nurse should follow certain precautions to prevent infection and control reservoirs of infection. Soiled dressings, body fluids, and urinary drainage bags act as reservoirs of infection. Changing the soiled dressings and emptying the urinary drainage bags help to eliminate reservoirs of infection. Instructing the patient to maintain adequate fluid intake promotes normal urine formation and outflow to flush the bladder and urethral lining of microorganisms, also preventing infection within the urinary system. The mouth and nose should be covered when coughing or sneezing to prevent the spread of airborne infections. Wearing disposable gloves while making contact with patients indicates that the nurse is following contact precautions.

The nurse, after administering antibiotics, is updating a patient's chart in the emergency room. What elements of the report does the nurse accurately document in order to limit nursing liability in case of a legal claim?

- Current medications given - Discontinued medications - Drug allergies *The patient's medical record needs an accurate description of the patient's health status. The information needs to be legible. The chart has a list of all the medications that are given during present care, any discontinued medications, and the drug allergies of the patient. It is not required or essential to mention the drug manufacturer or the size, shape, and color of the pills given. Information about the drug manufacturer is not related to the patient's health. The shape, size, and color of the pills do not have the potential to affect the patient's health or care.

A patient is suspected of having chickenpox. What are the modes of transmission of the organism that causes this infection? Select all that apply. - Vector - Vehicle - Droplet - Airborne - Direct contact

- Droplet - Airborne - Direct contact *Varicella zoster is the organism that causes chickenpox. Infection spreads by the airborne route, by the droplet nuclei, and by direct contact. Vector transmissions, such as mosquito and louse bites, do not cause chickenpox. Vehicles, such as contaminated items, water, and blood, do not cause chickenpox.

The nurse works in a hospital. What precautions are necessary to help prevent health care-associated infections? Select all that apply. - Frequently irrigate urinary catheters. - Insert drug additives to IV fluids. - Ensure a closed, urinary catheter drainage system. - Change the IV access site if inflamed. - Use aseptic technique when suctioning the airway.

- Ensure a closed, urinary catheter drainage system. - Change the IV access site if inflamed. - Use aseptic technique when suctioning the airway.

The nurse is caring for a patient who is at risk of falls due to improper gait. Which measures should the nurse take to ensure patient safety?

- Ensure that the patient wears rubber-soled slippers. - Move the patient on crutches or walkers after ensuring the patient's integrity. - Remove excess furniture from the path.

Which vaccinations are recommended to reduce the risk of infectious diseases in older adults? Select all that apply. - Flu vaccination - DTaP vaccination - Rubella vaccination - Varicella vaccination - Pneumonia vaccination

- Flu vaccination - Pneumonia vaccination *Flu and pneumonia vaccinations are recommended for older adults to reduce the risk of infectious diseases. DTaP vaccinations are effective for preventing whooping cough in children. Children are vaccinated for rubella infections. Varicella vaccination is used to prevent chicken pox in children.

Which action should the nurse avoid while opening a sterile item on a flat surface? - Keeping the inner contents sterile before use - Grasping 3.5 cm of the border to maneuver the field on the table surface - Holding the item with one hand while pulling the wrapper away with the other hand - Using 1 inch of the inner surface of the package border as a sterile field to add sterile items

- Grasping 3.5 cm of the border to maneuver the field on the table surface * The nurse should grasp only 2.5 cm (1 inch) of the border to maneuver the field on a table surface while opening a sterile item on a flat surface. The inner contents should be kept sterile before use to prevent infection. The nurse should hold the item in one hand while pulling the wrapper away with the other hand. The nurse should use nearly 1 inch of the inner surface of the package border around the edges as a sterile field to add sterile items.

What would a nurse use for a high-level disinfection? - Moist heat - Boiling water - Ethylene oxide gas - Hydrogen peroxide

- Hydrogen peroxide The nurse uses chemical sterilants such as hydrogen peroxide, iodophors, phenolics, and quaternary ammonium compounds for high-level disinfection. Moist heat, boiling water, and ethylene oxide gas are used for sterilization.

The nurse is learning about various modes of infection transmission. What are the sources for vehicle transmission of infection? Select all that apply. - Mosquitoes - Flies - IV fluid - Food - Water

- IV fluid - Food - Water

A registered nurse teaches a nursing student about the portal of exit of different organisms. Which statement made by the nursing student indicates a need for further learning? Select all that apply. - The skin is considered a portal of exit. - The hepatitis B virus can exit through blood. - Gastrointestinal portals of exit include emesis and drainage tubes. - In a patient with a urinary tract infection, organisms exit through drainage tubes. - The influenza virus is released from the body through the mucous membranes.

- In a patient with a urinary tract infection, organisms exit through drainage tubes. - The influenza virus is released from the body through the mucous membranes. *When a patient has a urinary tract infection, microorganisms exit during urination. The influenza virus is released from the body through the respiratory tract when a patient sneezes or coughs. The skin is considered as a portal of exit because any break in skin integrity allows pathogens to exit the body and is exhibited by the presence of purulent drainage. The hepatitis B virus can exit from wounds, venipuncture sites, and bloody stools. Gastrointestinal portals of exit include emesis, bowel elimination, and drainage of bile via surgical wounds or drainage tubes.

The nurse is caring for a patient who sustained a femur fracture following a fall. Which common physical hazards can increase the risk of falling?

- Inadequate lighting - Barriers in the normal walking path - Lack of safety devices in homes

A professor is teaching a group of nursing students about patient-inherent accidents. Which are examples of patient-inherent accidents in the hospital setting? Select all that apply. - Medication administration error - Improper insertion of a urinary catheter - Ingestion of a foreign substance - Pinching fingers in drawers - Self-inflicted cuts

- Ingestion of a foreign substance - Pinching fingers in drawers - Self-inflicted cuts

The nurse is assessing a group of patients in a health screening program. What should the nurse evaluate when assessing the infection risk in these patients? Select all that apply. - Inquire about diet and appetite. - Compare monthly earnings. - Assess immunization details. - Inquire about travel history. - Inquire about medication history.

- Inquire about diet and appetite. - Assess immunization details. - Inquire about travel history. - Inquire about medication history.

The nurse is teaching a group of nursing students about the normal defense mechanisms of the body against infections. Which statements are true about the skin as a primary defense against infections? Select all that apply. - It provides a barrier to microorganisms. - It helps in removing organisms when they adhere to outer layers of the skin. - It contains fatty acids that have an antibacterial action. - It helps in washing away particles containing microorganisms. - It contains microbial inhibitors.

- It provides a barrier to microorganisms. - It helps in removing organisms when they adhere to outer layers of the skin. - It contains fatty acids that have an antibacterial action. *The multilayered surface of the skin acts as a barrier against microorganisms. The periodic shedding of outer layers of the skin helps in removing organisms that adhere to the outer layers of the skin. The sebum secreted from the skin glands contains fatty acids that have antibacterial action. The skin does not help in washing away particles containing microorganisms or have microbial-inhibiting action. Saliva in the oral cavity helps to perform these actions.

A patient sustained minor burns in a fire at home. After stabilizing the patient, the nurse asks the patient to obtain a fire extinguisher at home. Which instructions should the nurse provide to the patient?

- It should be inaccessible to the children. - It should be placed on each level near an exit. - It should be placed in clear view. - It should be kept away from stoves and heating appliances.

Documentation is an important activity in nursing and should conform to organizational standards. Which are examples of organizations that address the quality of health care documentation?

- Joint Commission - National Committee of Quality Assurance (NCQA). - American Nursing Association Documentation of health care should conform to the standards of the Joint Commission and the National Committee of Quality Assurance (NCQA). This documentation ensures that the standards of care are maintained to uphold institutional accreditation and minimize liability. The American Nursing Association (ANA) sets standards to provide safe, effective, patient-centered, timely, efficient care to the patient.

The nurse is caring for a patient who is diagnosed with renal failure due to diabetes. The nurse has to pass the patient care to another nurse during change of shift. Which information should the nurse include in the hand-off report?

- Nursing diagnosis of the patient - Recent changes in objective measurements - Important information about family members

Which equipment is required for surgical hand asepsis? Select all that apply. - Sterile gloves - Paper facemask - Protective eyewear - Counter top surface - Surgical scrub sponge

- Paper facemask - Protective eyewear - Surgical scrub sponge

The senior nurse is discussing with student nurses the serious reportable events included in the list of the National Quality Forum (NQF). Which environmental events must be discussed? Select all that apply. - Physical assault of the patient - Patient death due to burns from facility equipment - Patient death associated with falls - Sexual assault of the patient - Patient death due to electrocution

- Patient death due to burns from facility equipment - Patient death associated with falls - Patient death due to electrocution

The nurse is caring for an older adult in the home and is concerned about the risk of injury in this patient. Which activities should the nurse perform to assess risk of injury in this patient?

- Perform a home hazard appraisal. - Inquire about the patient's visual acuity. - Observe the patient's posture and balance.

The nurse is training a health care provider on precautionary measures to avoid equipment-related accidents. Which should be included in the training? Select all that apply. - Placing a tag on faulty instruments - Promptly reporting the malfunctions - Following proper hand hygiene - Following transmission-based isolation - Assessing potential electrical hazards

- Placing a tag on faulty instruments - Promptly reporting the malfunctions - Assessing potential electrical hazards

A patient with a urinary tract infection is hospitalized due to severe discomfort. The primary health care provider advises the nurse to provide supportive therapy to the patient. Which actions of the nurse are included when providing supportive therapy? Select all that apply. - Provide adequate rest - Provide adequate nutrition - Maintain proper hand hygiene - Monitor the patient's response to drug therapy - Use standard precautions during therapy

- Provide adequate rest - Provide adequate nutrition *Patients who require attentive care are provided with supportive therapy, which includes providing adequate rest and nutrition to the patient to improve the patient's defense mechanisms against infections. Maintaining proper hand hygiene, monitoring the patient's response to drug therapy, and the usage of standard precautions while handling patients during therapy are general responsibilities of the nurse while caring for a patient with exogenous or endogenous infections.

The nurse is using a chlorine compound at room temperature to clean surgical instruments contaminated by blood, pus, urine, and saliva. Which factors would reduce the efficacy of the disinfectant? Select all that apply. - Pus, blood, urine, and saliva were not rinsed off the instruments before application of the disinfectant. - Soap and water were used to clean the instruments before application of the disinfectant. - The instruments were thoroughly rinsed off with water before application of the disinfectant. - The chlorine solution is diluted. - The room where the instruments are being disinfected is at a normal temperature.

- Pus, blood, urine, and saliva were not rinsed off the instruments before application of the disinfectant. - Soap and water were used to clean the instruments before application of the disinfectant. - The chlorine solution is diluted. *Chlorine is a disinfectant and the nurse should be aware of all the factors influencing the efficacy of a disinfectant. Organic materials including blood, pus, saliva, and urine tend to reduce the efficacy of the disinfectant. Likewise, soap causes certain disinfectants to become less effective. Diluting a disinfectant also reduces its efficacy. For the disinfectant to work best, the instruments should be rinsed thoroughly in water before using the disinfectant. Disinfectants tend to work best at room temperature, so the room where the nurse is cleaning the instruments should be at a normal room temperature.

While caring for a patient with testicular cancer in a health care setting, the nurse observes that the patient develops a urinary tract infection. Which actions of the nurse could be responsible for the development of this health care-associated infection? - Repeated irrigation of the catheter - The use of a contaminated antiseptic solution - Improper specimen collection technique - Improper care of the intravenous (IV) insertion site - Improper disposal of respiratory exudates

- Repeated irrigation of the catheter - Improper specimen collection technique *Health-care associated infections result from the delivery of health services in a health care facility. Repeated catheter irrigations or improper specimen collection techniques can cause urinary tract infections. The use of contaminated antiseptic solutions may cause surgical or traumatic wounds. The improper care of the intravenous (IV) insertion site may affect the patient's bloodstream. Improper disposal of respiratory exudates may cause respiratory tract infection.

The nurse finds that a patient is a chain smoker and bathes more than five times a day. On assessing medical reports, the nurse finds that the patient is on contraceptive therapy. Based on the nurse's findings, which of the patient's body defense mechanisms may weaken? Select all that apply. - Saliva - Sebum - Flora in the vagina - Tearing and blinking of the eyes - Macrophages in the respiratory tract - Shedding of the outer layer of skin cells

- Saliva - Sebum - Flora in the vagina - Macrophages in the respiratory tract

To ensure safe use of oxygen in the home by a patient, which teaching points should the nurse include?

- Smoking is prohibited around oxygen. - Do not use electrical equipment around oxygen. - Special precautions may be required when traveling with oxygen. *When oxygen is in use, the nurse must teach patients to take precautions to prevent fire and protect the patient. These precautions include posting "Oxygen in Use" signage, not using oxygen around electrical equipment or flammable products, properly handling oxygen cylinders/containers, ensuring that tubing is unobstructed, not adjusting liter flow without a physician's order, and taking precautions when traveling with oxygen.

The nurse finds that a patient has sustained seizures lasting longer than 5 minutes. Which strategies should be included in the care plan to prevent hypoxia in this patient?

- Suctioning the airway - Maintaining a patent airway - Providing oxygen via nasal cannula *Seizures beyond 5 minutes may deprive the patient of oxygen. Suctioning should be performed, bevcause it is needed to keep the airway patent. The airway and oxygenation should be maintained either via nasal cannula or a face mask. Placing the patient in prone position would obstruct the airway and thus should be avoided. An oral airway should be attempted only if access is easy and the breathing is impaired.

The nurse is caring for a patient who has undergone abdominal surgery. The patient informs the nurse of discomfort in the abdomen and is unable to turn to the left side. The nurse finds that the patient has a temperature of 100.2° F, a respiratory rate of 28 breaths/minute, and a heart rate of 98 beats/minute. Which data should the nurse chart under the O in SOAP charting?

- Temperature 100.2° F - Respiratory rate 28 breaths/minute - Heart rate 98 beats/minute

A patient sustains an injury from a fall while on a hospital unit. The nurse makes an incident report. What is the purpose of the incident report?

- This report helps in identifying loopholes in the operation of the healthcare system. - This report helps in providing good, quality healthcare - This report helps to identify the need to change a procedure or policy.

A patient in a medical-surgical unit develops an acute episode of seizures. Which nursing interventions are performed to ensure a clear airway and free drainage of saliva?

- Turn the patient to one side. - Tilt the patient's head slightly forward. *During seizures the patient may choke due to pooling of secretions that may obstruct the airway. To ensure a patent airway, the patient should be turned to one side, so that the tongue does not interrupt the airway. Tilting the head slightly forward helps in free drainage of saliva. The prone position increases the risk of asphyxiation due to obstruction of airways. The supine position may not provide a clear airway, because rolling back of the tongue might interfere with the airway. A straight head that is tilted backwards increases the risk of airway obstruction and aspiration of saliva.

The nurse is changing the dressing of a patient at a bedside table. Which are the techniques of asepsis that the nurse should perform? Select all that apply. - Wearing a mask - Using protective eyewear - Using an instant alcohol hand antiseptic - Having well-manicured nails - Washing hands with soap and water followed by rinsing under a stream of water for 15 seconds

- Using an instant alcohol hand antiseptic - Having well-manicured nails - Washing hands with soap and water followed by rinsing under a stream of water for 15 seconds *Asepsis is the cleaning technique adopted for reducing the number of organisms present and preventing their transfer. It includes techniques such as using an instant alcohol hand antiseptic, having trimmed nails, and washing hands with soap and water. Wearing a mask and using protective eyewear are used in surgical asepsis.

The nurse is analyzing the laboratory results of a hospitalized patient. The nurse reads the differential count of white blood cells and makes a note that the eosinophils, basophils, and monocytes are within normal limits. The neutrophilic count, which should be between 55% and 70%, is increased to 90%. The lymphocytes, which should be between 20% and 40%, are increased to 60%. What does the increased count indicate? Select all that apply. - Sepsis - Viral infection - Tuberculous infection - Chronic bacterial infection - Acute suppurative infection

- Viral infection - Chronic bacterial infection - Acute suppurative infection *Lymphocytes are increased when there is chronic viral and bacterial infection. Neutrophils are white blood cells that ingest and destroy microorganisms by a process called phagocytosis. They are increased in cases of acute suppurative infection. Lymphocytes are decreased when there is sepsis, while monocytes increase in tuberculous infection.

A patient with influenza is admitted to a hospital. Which infection control precautions should the nurse take to prevent spread of the virus? Select all that apply. - Wearing gloves while reviewing the medical report - Wearing a surgical mask within 3 feet of the patient - Wearing a sterile gown while entering the patient's room - Maintaining proper hand hygiene during the assessment - Placing the patient in an airborne infection isolation room

- Wearing a surgical mask within 3 feet of the patient - Maintaining proper hand hygiene during the assessment *Influenza is an example of an infection that is transmitted by large droplets. Therefore, droplet precautions are required, which include wearing a surgical mask within 3 feet of the patient and maintaining hand hygiene during the assessment. While reviewing the patient's medical report, the nurse does not need to wear gloves. The patient is placed in an airborne infection isolation room when an airborne infection is present or suspected, such as tuberculosis. Contact precautions require a gown and gloves, as in the case when caring for a patient with Clostridium dificile (C. dif) or drug resistant microorganism strains (MRSA, ORSA, VRE)

A nurse manager is educating the nursing staff on the importance of security with the implementation of the electronic health record (EHR) on the unit. What points does the manager emphasize?

-Do not share passwords with anyone. -Do not leave the patient's medical record open unattended on a computer screen. -Do not log in with someone else's user access.

The nurse, who is caring for a patient on a ventilator, electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at a high risk for aspirating because the head of the bed is not elevated high enough. This warning is known as what type of system?

A clinical decision support decision

The National Quality Forum is collecting information from a health care facility about serious reportable events that have occurred. Which event should be listed as a care-management event? A. Wrong surgical procedure was performed B. Patient suicide within a health care facility C. Death due to medication error D. Sexual assault within the health care facility

A death caused by the health care facility's medication error should be reported as a care-management event. *The performance of the wrong surgical procedure should be reported as a surgical event. A patient committing suicide during the stay in the health care facility should be reported as a patient-protection event. A sexual assault in the health care facility is reportable as a criminal event.

The nurse is calculating the fall risk score of an 85-year-old patient using a standard fall assessment tool. Which factors contribute to the patient's overall fall risk?

A fall assessment tool must consider several aspects of a patient's condition and history in order to determine the patient's overall fall risk. The patient's age, fall history, and current medications are considered because older patients are more likely to fall, as are patients with a history of falling, or patients who are on medications that make them dizzy or groggy or that impair their motor skills. Gender and weight are not factors considered in standard fall assessment tools because patients of any gender or weight can be at risk for falling.

The senior nurse is teaching a group of nursing students about the prevention of hospital fires. Which activities should be performed during a fire?

A fire can be extinguished if the oxygen supply to the fire is cut off. Therefore, important measures to extinguish a fire include using a fire extinguisher, turning off sources of oxygen, and closing all doors and windows.

A patient with postural hypotension is hospitalized. Which safety measure should the nurse implement during ambulation?

A gait belt

A patient is experiencing unilateral neglect related to a brain injury. How can the nurse help this patient to restore normal capabilities?

A patient who has had a brain injury may have unilateral neglect, which can increase the patient's risk for falling. The patient should be reminded to scan the home environment while walking to prevent the risk of falling. Encourage family members to eat with the patient so they can remind the patient to try to use the affected side of the mouth to eat the food. Teaching the patient to touch the affected side of the body with the unaffected hand helps the patient to become aware of the affected side.

In a trauma unit a patient who was injured in a traffic accident begins having seizures. How should the nurse position this patient to prevent traumatic injury due to seizures?

A patient who is having seizures may sustain trauma due to unsafe surroundings. If the patient is in a bed, the side rails should be raised to prevent the patient from falling off the bed. If the seizures are occurring while the patient is on the floor, then the floor must be cleared of all furniture to prevent injury. Pillows usually cause suffocation; therefore, they should not be used. The nurse should support the patient's head either on the lap or by using a pad. During active seizures, the patient should not be shifted to a bed, because it may further increase the risk of injury to the patient.

A registered nurse is explaining the Health Insurance Portability and Accountability Act (HIPAA) regulations to a student nurse. Which response by the student nurse regarding HIPAA regulations needs correction?

According to HIPAA regulations, any patient information should remain confidential. Therefore, patient information should never be printed for personal use. HIPAA allows access to electronic health records through user login information to ensure confidentiality and security. The main criterion of HIPAA regulations is to protect the health care information of the patient. At the same time, gaining access to the health information is possible by obtaining written permission from the patient.

The nurse is assessing a group of patients in the medical surgical unit and ties colored wristbands (as per the American Hospital Association guidelines) to the patients based on the assessment. Which group of patients should receive red wristbands?

According to the recommendations of the American Hospital Association (AHA), standardized wristband colors should be used for patients. Red bands should be given to patients with allergies. Yellow bands should be given to patients who are at risk of falls. There is no specific color for identifying patients with psychiatric illness according to the AHA. Purple bands are given to patients who have a do-not-resuscitate (DNR) order.

The nurse is recording specific demographic information about a patient in a hospital. Which section of the traditional source record does the nurse use to record this information?

Admission sheet *Demographic information includes the legal name, identification number, gender, age, birth date, marital status, and occupation of the patient. Demographic information also includes health insurance, nearest relative to notify in an emergency, religious preference, name of attending physician, and date and time of patient's admission. This information is included on the admission sheet section.

The nurse is caring for a patient who is at risk for infection. The nurse isolates the patient in a room with positive airflow and the patient is instructed to use a mask when he or she is out of their room. What condition may the patient have? - Laryngeal tuberculosis - Streptococcal pharyngitis - Disseminated varicella zoster - Allogeneic hematopoietic stem cell transplants

Allogeneic hematopoietic stem cell transplants

The nurse cares for a patient who is scheduled for surgery. Which objects would require high-level disinfection with phenolics? - Stethoscopes - Urinary catheters - Surgical instruments - Anesthesia equipment

Anesthesia equipment *Phenolics are used for high-level disinfection. Semi-critical items such as anesthesia equipment, endoscopes, and endotracheal tubes require high-level disinfection or sterilization. Noncritical items such as stethoscopes require a disinfection of surfaces. Critical items such as urinary catheters and surgical instruments require sterilization.

A patient who had a hysterectomy 10 days ago has come for a follow-up visit. The patient is experiencing pain and itching at the incision site. After assessment, the health care provider suspects the incision site is infected. Which interventions would help control infection? Select all that apply. - Reduce water intake. - Administer antibiotics. - Administer anxiolytics. - Provide adequate nutrition. - Monitor response to drug therapy.

Antibiotics should be administered to control the wound infection. Adequate nutrition is a supportive therapy, which helps in wound healing and recovery from infection. The response to drug therapy should be monitored to plan further management. Reducing water intake is not advisable; instead adequate water intake should be encouraged. Administration of anxiolytics is only considered for anxious patients and not for wound infection.

A critical pathway in an orthopedic unit indicates that a patient should be afebrile, normotensive, and eupneic after knee replacement surgery. The nurse performs a postoperative examination of a patient's status after left knee replacement surgery and finds that the patient is experiencing a low-grade temperature. What is this finding called?

Any unexpected outcome of a procedure, unmet goals, or an intervention not indicated in the critical pathway is called a variance. *A positive variance is a positive, unexpected outcome, such as when a patient starts walking a day earlier than expected after surgery.

The nurse is instructing the mother of an infant not to leave the mesh sides of a playpen lowered. Which accidental trauma can be prevented by this intervention?

Asphyxiation

The nurse is caring for a patient in the home and is checking for hazards. Which assessment made by the nurse is priority?

Assessing the adequacy of light

The nurse is performing fall prevention measures for a patient. During which step of the nursing process does the nurse perform "Timed Get up and Go" (TUG) if a patient is able to ambulate?

Assessment

The nurse interprets the subjective and objective data and diagnoses a problem in a patient. Which step of the nursing process reflects this interpretation, according to SOAPIE (subjective, objective, assessment, plan, intervention, and evaluation) format?

Assessment *In the assessment step, the problem is diagnosed based on the data provided, or subjective data, and the data observed, or objective data. After the diagnosis of the problem, the nurse or caregiver develops a care plan for the patient. In the evaluation step, the outcomes are evaluated after sufficient care is provided. The nursing actions developed from the plan will be implemented in the intervention step of the nursing process.

The nurse is preparing a patient for discharge. What should the nurse include in the discharge summary forms?

At the time of discharge, a patient should be provided with a discharge summary form in which home care is noted. Dietary restrictions, follow-up care, and emergency contact numbers should be included in the discharge summary forms.

Which normal flora of the human colon can cause an infection when it enters the bloodstream? - Escherichia coli - Candida albicans - Bacteroides fragilis - Plasmodium falciparum

Bacteroides fragilis *Escherichia coli causes gastroenteritis in the colon. Candida albicans causes candidiasis, pneumonia, and sepsis. Plasmodium falciparum causes malaria.

A group of nurses are discussing the advantages of using computerized provider order entry (CPOE). Which statements indicate that the nurses understand the major advantage of using CPOE?

CPOE eliminates the need for someone to transcribe the orders because it allows the provider to enter the order directly; therefore, CPOE reduces transcription errors.

A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-old son drank. Which is the most important instruction the nurse should give to this parent?

Call the Poison Control Center.

A patient has been locked in a poorly ventilated room containing a furnace. Which condition is likely to be observed in the patient after a period of time?

Carbon monoxide poisoning

According to Edelman and Mandle's strategies of health promotion, which is classified as a passive strategy?

Clean water laws

A child in the hospital starts to have a grand mal seizure while playing in the playroom. Which is the most important nursing intervention during this situation? A. Begin cardiopulmonary respiration. B. Restrain the child to prevent injury. C. Place a tongue blade over the tongue to prevent aspiration. D. Clear the area around the child to protect the child from injury.

Clear the area around the child to protect the child from injury. * Once a seizure begins, the nurse needs to monitor the patient and provide a safe environment.

A patient who is on antibiotic therapy visits the primary health care provider with severe diarrhea. The primary health care provider diagnoses the patient with antibiotic-induced diarrhea. Which microorganism causes antibiotic-induced diarrhea? - Bacteroides fragilis - Clostridium difficile - Staphylococcus aureus - Legionella pneumophila

Clostridium difficile

Which type of transmission-based precaution requires a gown and gloves? - Droplet precautions - Contact precautions - Airborne precautions - Protective environment precautions

Contact precautions require a gown and gloves because the handling of contaminated body fluids may cause infections. Droplet precautions require a surgical mask within three feet (0.9 meters) of a contagious patient. Airborne precautions require a specially equipped room with a negative airflow, referred to as an airborne infection isolation room. Protective environment precautions require a specialized room with a positive airflow set to greater than 12 air exchanges per hour.

A patient is experiencing a seizure during acute hospitalization. Which measures facilitate breathing and reduce the risk of musculoskeletal injury?

During seizures, patients may have altered breathing and may be at risk of sustaining musculoskeletal injury. Loosening the patient's gown facilitates breathing movements by reducing the effort required for chest expansion. If the patient is standing or sitting, guide the patient to the floor and protect the head by cradling it in the lap or placing a pad under the head. Limbs should be held loosely if the patient is flailing. Tightening the waist belt restricts abdominal expansion, further aggravating respirations in the patient. The patient should not be restrained during seizure activity, because this increases the chance of musculoskeletal injury.

Which skill is implemented by the nurse when planning to prevent falls in patients?

During the planning phase, the nurse gathers the equipment and performs hand hygiene. During assessment, the nurse reviews the patient's medication. During implementation, the nurse makes the patient's environment safe. During assessment, the nurse determines if the patient has a history of recent falls.

Which restraint should the nurse use to prevent nerve injury?

Elbow restraint. Elbow restraint, or the freedom splint, is commonly used with infants and children to prevent elbow flexion. This helps keep the elbow extended and prevents nerve injury in cases where the IV line is placed in the antecubital fossa. *Elbow restraint, or the freedom splint, is commonly used with infants and children to prevent elbow flexion. This helps keep the elbow extended and prevents nerve injury in cases where the IV line is placed in the antecubital fossa.

The nurse is giving information to a group of caregivers about electronic health records (EHRs). What information about the EHR should the nurse offer them?

Electronic health records integrate all the pertinent patient information into one record regardless of the number of times the patient visits the healthcare provider. Electronic records perform checks for regulatory requirements and provide a means to compare ongoing clinical data with baseline information.

Which nursing process step is demonstrated when the nurse performs a visual examination on a patient who becomes too agitated when approached?

Evaluation *Evaluation is the step involved when the nurse performs a visual check on a patient. Assessment is involved when the nurse assesses a patient's behavior. Planning involves gathering equipment to promote organization and performing hand hygiene to reduce the transmission of microorganisms. Implementation involves adjusting the bed to a proper height and inspecting the area to prevent injuries during restraint application.

Which statement is true regarding the donning and removing of caps, masks, and eyewear? - Surgical masks and eyewear should be worn only inside the sterile field. - Eyewear should be worn only when the procedure has a risk of splashing. - Surgical masks should be worn first and then a clean cap should be worn to cover the hair. - Surgical masks should be removed after the completion of the procedure even if it takes several hours.

Eyewear should be worn only when the procedure has a risk of splashing.

The nurse is caring for a patient who has been diagnosed with pneumonia. The nurse is reviewing the assessment details of the patient: "Blood pressure is 150/90 mm Hg; pulse is 92 beats/minute, and the respiratory rate is 22 breaths/minute. The patient seems to have difficulty breathing. Sounds are produced when the patient exhales. Auscultation reveals rhonchi in the lower lung bases. Copious amounts of phlegm have been produced since morning." A senior nurse finds this to be poor quality of documentation. Which statements in the documentation are considered to be poor quality documentation and informatics?

Good quality documentation should be factual, accurate, current, complete, and organized. Using the word seems indicates that the nurse is not communicating a fact but rather, stating her opinion. "Sounds are produced" are terms that indicate the nurse lacks knowledge. It should be written as "wheezing is present while exhaling." By documenting "copious amounts," the nurse is not providing a detailed enough description of the amount, color, and consistency of the sputum. The statement about the vital signs has all the required information accurately documented. Recording the presence of rhonchi in the lower bases of the lungs on auscultation is also a correct statement.

Information about repeated observations and measurements such as vital signs, daily weights, and intakes and outputs are included under the

Graphic sheet and flow sheet section.

The nurse faxes a patient's medical record to an unknown number. Which law is the nurse violating?

HIPAA protects the patient's privacy regarding health information and governs the management of patient information. The illegal exchange of the patient's health information violates this act. ARRA encourages electronic communication among the health care bodies and mandates that all medical records are to be kept electronically from 2014 forward. HITECH rewards the primary healthcare provider and facilities that adopt the electronic medical record (EMR)/electronic health record (EHR). The TJC act does not exist. *Study Tip: To remember that the HIPAA law is the one that covers privacy of health information, think, "Hip, HI P AA hooray that our privacy is protected!"

You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?" Which option is the best response?

HIPPA provides you with greater control over your personal health care information

At the end of a shift, the nurse documents a patient's condition, anticipated condition, medications, and nursing interventions fulfilled so that the next nurse can follow the appropriate treatment plan and care for the patient. What is this kind of report?

Hand-off reports are prepared any time patient care is transferred from one caregiver to another in the healthcare setting. The report prepared during a shift change is also a hand-off report. A discharge summary is the summary of the patient's hospital stay, condition at discharge, diagnosis, prognosis, and treatment plan and goals. An incident report records any incident happening that is inconsistent with the routine care of a patient or with the routine operation of a health care unit, such as a fall or injury from medical equipment. A telephone report is made when the nurse reports any significant changes in the patient's health condition to the healthcare provider or other medical personnel.

A patient is diagnosed with a bronchial airway obstruction after performing a bronchoscopy. Which type of infection may the patient contract after performing the test?

Iatrogenic infections are caused by an invasive diagnostic or therapeutic procedure. Patients who underwent a bronchoscopy and are treated with broad-spectrum antibiotics are at a greater risk of developing this type of infection. *The use of broad-spectrum antibiotics for the treatment of infection may cause a suprainfection. An exogenous infection is caused by organisms that are found outside of an individual. Endogenous infections occur when a patient receives broad-spectrum antibiotics that alter the normal flora.

The nurse caring for a patient in a home care setting needs detailed documentation. What are the purposes of the documentation?

In a home care setting, proper documentation is required for the justification of reimbursement of the care provided. It is also needed to provide information for the quality of work. A detailed document is required for an interprofessional plan of care and to provide the health care team with the detailed knowledge to facilitate the coordination of care.

In a hospital, a use of restraint is ordered and renewed every two hours. What might be the age of the patient?

In hospital settings, each original restraint order and renewal is limited to 8 hours for adults, 2 hours for ages 9 to 17, and 1 hour for children under age 9. Therefore, a 15-year-old patient will require ordering and renewing of the restraint order every 2 hours. The 8-year-old child will require ordering and renewal every 1 hour. The 21-year-old and 35-year-old patients will require renewal every 8 hours.

How is proper documentation of a patient's health information useful to medical insurance companies?

In order to determine healthcare reimbursements that have to be provided for the patient, insurance companies have to first determine the diagnosis-related group (DRG) of the patient. This can be done by referring to the patient's documented reports. Thus, it is very important that the information pertaining to the patient's health is well documented.

According to the National Quality Forum, which event is included under patient-protection events? - Abduction of a patient - Infant discharge to the wrong person - Disability associated with a medication error - Surgery performed on the wrong body part

Infant discharge to the wrong person is included under patient-protection events. * Events like the abduction of a patient are considered to be criminal events. Disability associated with a medication error is included under care-management events. Surgeries performed on the wrong body part are included under surgical events.

Which group is at the highest risk for lead poisoning?

Infants and children

A 65-year-old patient is undergoing treatment for chronic bronchitis and develops a health care-associated exogenous infection. What could be the reason for this condition? - Infection caused by Aspergillus - Infection caused by Streptococci - Infection caused during bronchoscopy - Infection caused by broad spectrum antibiotics

Infection caused by Aspergillus *Exogenous infections are caused by microorganisms found outside the individual such as Aspergillus, Salmonella and Clostridium tetani. Therefore, a patient infected with Aspergillus is considered to have an exogenous infection. Endogenous infections are caused by organisms such as Streptococci or Enterococci. Infections caused by a bronchoscopy or the administration of broad spectrum antibiotics are iatrogenic infections.

A patient is admitted in the hospital with a diagnosis of meningococcal pneumonia. Which is the priority nursing intervention in this condition? - Isolating the patient - Performing oral hygiene - Providing antimicrobial therapy - Keeping the patient well hydrated

Isolating the patient *Meningococcal pneumonia is an infectious droplet infection. Therefore, the patient should be isolated first to prevent the transmission of the disease. The nurse should isolate the patient before performing oral hygiene. The nurse should provide antimicrobial therapy after isolating the patient. The nurse should maintain adequate hydration to promote the patients' health and reduce the risk of infections.

A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? - It keeps an incontinent patient's skin dry. - It can get caught in the linens or equipment. - It obstructs the normal flushing action of urine flow. - It allows the patient to remain hydrated without having to urinate.

It obstructs the normal flushing action of urine flow. - The presence of a catheter in the urethra breaches the natural defenses of the body . The reflux of microorganisms up the catheter lumen from the drainage bag or backflow of urine in the tubing increases the risk of infection. A catheter can help in keeping an incontinent patient's skin dry, but that normally does not lead to a urinary tract infection. The catheter can become caught up in the linens or with other equipment, but that does not cause a urinary tract infection. A patient with a catheter is producing urine and urinating; thus the patient is staying hydrated and still urinating.

A patient has accidently consumed kerosene. Which nursing intervention would further complicate the patient's condition?

Kerosene is a poisonous substance. Inducing vomiting in a patient who has consumed kerosene is dangerous, because it can cause aspiration. Maintaining the airway is the primary measure to reduce the risk of aspiration and is thus important in cases of kerosene poisoning. Oxygen administration is helpful in kerosene poisoning. Measuring oxygen saturation is an important intervention for this patient, because it helps to identify the need for intubation and other assistive measures.

The nurse is changing the dressing of a patient with cellulitis who has been admitted to the hospital. Meanwhile, another health care provider in the same unit asks for the nurse's help with the blocked intravenous line of another patient. What should the nurse do?

Leave the first patient, perform hand hygiene, and then ensure the patency of the IV line.

On examination, the nurse notes that a patient's surgical wound has become edematous, red, and tender. There is also new onset fever and laboratory results show leukocytosis. Which is the priority nursing intervention? - Use clean technique to change the dressing. - Reassure the patient and recheck the wound later. - Notify the healthcare provider and support the patient's fluid and nutritional needs. - Alert the patient and caregivers to the presence of an infection to ensure care after discharge.

Notify the healthcare provider and support the patient's fluid and nutritional needs. *Early intervention can reduce the risk of sepsis caused by the progression of infection. Therefore, it is important to notify the healthcare provider for further orders and support the patient's fluid and nutritional needs. Fever depletes body's fluid stores, which can result in an increased risk of dehydration and providing proper nutrition promotes healing.

A nurse instructs a patient to color code the hot water faucets and dials. What might be the possible age group of the patient?

Older adults are instructed to color code the hot water faucets and dials to prevent burns and scalds. The color coding makes it easier for an older adult to know which is hot and which is cold.

Which event is classified as an environmental event on the National Quality Forum list?

Patient death associated with a fall in the health care facility is classified as an environmental event on the National Quality Forum list. *Patient death due to physical assault in a health care facility is reportable under criminal events. Patient death due to contaminated drugs in a health care facility is reportable as a product or device event. Patient death due to spinal manipulative therapy in health care facility is reportable under care management events.

Which patient should be provided with a yellow wristband according to American Hospital Association (AHA)?

Patient with risk of falls

A patient asks for a copy of her medical record. What is the nurse's best response?

Patients have the right to read their medical records, but the nurse should always know the facility policy regarding personal access to medical records because some require a nurse manager or other official to be present to answer questions about what is in the record. Families may read the records only when the patient has given permission.

An 80-year-old patient demonstrates some confusion but no anxiety. The nursing assessment reveals that the patient is a fall risk because the patient continues to get out of bed without help despite frequent reminders. Which nursing intervention should be initiated to prevent falls for this patient?

Place a bed alarm device on the bed. *The nurse should consider and implement alternatives as appropriate before using a restraint. A bed alarm is an alternative that the nurse implements independently.

What is an appropriate way for the nurse to dispose of printed patient information?

Place in a secure canister marked for shredding *Confidential patient information should be shredded. It is generally collected in large, secure containers and shredded at scheduled times. Ripping the information or placing it in a paper chart does not ensure patient confidentiality. Burning paper is a fire hazard and is not allowed on the nursing units.

A patient is being provided artificial respiration through ventilators in an intensive care unit. Unfortunately there has been a fire on the unit. What should the nurse do in this situation?

Provide manual respiration through a bag-valve-mask device.

The nurse works in the radiology department of a hospital. Which guidelines should the nurse follow with respect to patient safety?

Radiation is a health hazard, so hospitals have strict guidelines concerning care of patients receiving radiation. The patient should wear a lead apron to protect against the radiation. The patient should spend a minimum amount of time in the radiation zone and should maintain safe distance from the source of radiation. The patient should be counseled that radiation could be harmful, and the patient should not move freely in the radiation zone.

The nursing instructor is teaching students about legal guidelines for documentation. What guidelines for documentation should the nurse include?

Records must be accurate, factual, and objective. Errors in recording can lead to errors in treatment or may imply an attempt to mislead or hide evidence. You are accountable for the information that you enter into a patient's record. Critical statements can be used as evidence for nonprofessional behavior or poor quality of care. Using shorthand is not recommended because, if the charting became illegible, it might appear as if the nurse attempted to hide information or deface a written record.

A patient was diagnosed with left-sided neglect after suffering a cerebrovascular accident. Which nursing intervention would be most effective to ensure the patient's safety?

Reminding the patient to scan the environment while walking

The nurse is assessing a patient with impaired mobility. The nurse observes poor coordination and muscle weakness. Which risk does the nurse anticipate in the patient?

Risk of injury

Which safety precaution should be taken by the patient with muscle weakness while walking?

Rubber-soled shoes are used by the patients with muscle weakness because they provide better grip on the floor. Side rails are placed on the sides of the bed to help patients in sitting and standing, but would not help the patients with ambulation. Crutches are assistive aids used by the patient who are unable to walk without support. Belt restraints are not used to support ambulation.

A patient admitted to the hospital for fever, diarrhea, and vomiting receives the lab reports. The neutrophils are 20%. The patient becomes worried and asks the nurse about it. What is the probable reason for a reduced neutrophil count? - Sepsis - Allergy - Viral infection - Mild food poisoning

Sepsis *The patient has a reduced neutrophil count , which is seen in overwhelming bacterial infections such as sepsis. In these cases, more neutrophils are destroyed faster than they can be reproduced by the bone marrow. Allergy, viral infections, and mild food poisoning are not associated with low neutrophil counts.

According to the National Quality Forum, which event is considered a care management event?

Stage III pressure ulcers acquired after admission to a health care facility

The nurse assists a surgical technician in preparing a sterile field. Which action made by the nurse indicates a need for correction? - Allowing the flap to lie flat on the table's surface - Grasping the outer edge of the tip of the outermost flap - Standing close to the sterile field while opening the last flap - Opening the outermost flap of the sterile kit away from the body

Standing close to the sterile field while opening the last flap *While preparing a sterile field, the nurse should open the last flap while standing away to field as to avoid contamination. The flap should be allowed to lie flat on the table surface. The outer edge of the tip of the outermost flap should be grasped because the outer surface of the package is considered unsterile. The outermost flap of the sterile kit should be kept away from the body to prevent contamination.

Which type of specimen is collected by using a sterile tongue blade? - Stool specimen - Urine specimen - Blood specimen - Wound specimen

Stool specimen *Stool specimens are collected with sterile tongue blades. Urine specimens are collected with needleless safety syringes. Blood specimens are collected with 20-mL needle-safe syringes. Wound specimens are collected with sterile cotton-tipped swabs or syringes and collection tubes.

A 10-year-old patient with symptoms of a throat infection develops rheumatic fever. What could be the possible causative organism for the throat infection and rheumatic fever in this patient? - Staphylococcus aureus - Streptococcus (beta-hemolytic group A) - Streptococcus (beta-hemolytic group B) - Methicillin-resistant Staphylococcus aureus

Streptococcus (beta-hemolytic group A)

In a pediatric ward, one of the newborns died of sudden infant death syndrome (SIDS). Which nursing measure lowers the risk of death due to SIDS?

Sudden infant death syndrome (SIDS) is a condition in which the infant dies due to an unexplained cause. The American Academy of Pediatrics recommends having the baby sleep on his or her back to reduce the risk of sudden infant death syndrome (SIDS).

For a patient who has wrist and ankle restraints, which position will place the patient at risk of aspiration?

Supine *A patient with wrist and ankle restraints will be at a risk for aspiration if he or she is positioned in the supine position.

Which standardized assessment tools are used for receiving health care funding from the Centers for Medicare and Medicaid Services?

The Centers for Medicare and Medicaid Services uses the assessment tools such as the Resident Assessment Instrument and Minimum Data Set (RAI/MDS). These are standard protocols for managing and caring for residents in a long-term facility. Nursing records should meet these standards for proper reimbursement.

Nurses' notes include information about ......

The assessment, nursing diagnosis, planning, implementation, and evaluation of patient care.

The nurse is reviewing the manufacturer's instructions for restraint application before entering the patient's room. Which step in the nursing process is the nurse demonstrating?

The basic step involved in this situation is assessment. Assessment involves the nurse reviewing the manufacturer's instructions for restraint application before entering the patient's room, so that the nurse can be familiar with all the devices used for the patient. *Planning involves gathering equipment and performing hand hygiene to reduce transmission of microorganisms. Evaluation occurs after application and involves observing the patient for signs of injury and checking vital signs. Implementation involves adjusting the bed to a proper height and inspecting the area to prevent injuries during restraint application.

Which statement regarding health care-associated infections requires correction? - The costs of health care-associated infections are reimbursed. - Health care-associated infections can significantly increase the cost of health care. - The length of hospitalization influences the risk of health care-associated infections. - Health care-associated infections result from the delivery of health services in a healthcare facility.

The costs of health care-associated infections are reimbursed.

Communication among the members of a healthcare team is essential to providing quality care to patients. Which are the modes for exchanging information among the members of the healthcare team?

The exchange of information among the healthcare team members is done through written reports and oral communication.

The nurse assesses a patient postoperatively and charts the findings in a SOAP note. What elements are integral to the SOAP note?

The expanded form of the SOAP note format is S for subjective,O for objective,A is for assessment, and P is for plan. Intervention, order, and problem are not elements of a SOAP note. The PIE note contains intervention and problem. Study Tip: Practice writing SOAP and PIE notes until you have the elements memorized. For a SOAP notes rehearsal in a study group, take turns pretending to be the patient while the others record the subjective presentation. Then have one study member play the nurse, gathering objective information. Discuss possible diagnoses and what would go into the plan.

A patient is diagnosed with a methicillin-resistant Staphylococcus aureus (MRSA) infection of the respiratory system and has a productive cough. The nurse auscultates the lungs and finds that the breath sounds are clear. The disposable thermometer used by the nurse indicates fever. The nurse collects a urine specimen of the patient as ordered. What interventions should the nurse perform to prevent the spread of infection? Select all that apply. - Confirm fever using an electronic thermometer. - Clean the bell and diaphragm of the stethoscope with soap and water. - Place specimen containers on a clean paper towel in the patient's bathroom. - Label the specimen in the bathroom where samples of patients are collected. - Review agency policies and precautions necessary for the specific isolation system.

The nurse should be aware of the equipment used in an isolation room and the indications for isolation. If the disposable thermometer indicates fever, it is important to confirm it using an electronic thermometer. The nurse also needs to review agency policies and procedures. Methicillin-resistant Staphylococcus aureus (MRSA) can cause a health care-associated infection (HAI). Therefore, the nurse has to take precautions to prevent the spread of infections within the hospital. Specimen containers are to be kept in the patient's bathroom appropriately. If a stethoscope is to be reused, the diaphragm or bell should be cleaned with alcohol, rather than soap, and should be set aside on a clean surface to dry completely. After the sample is collected, labeling on the specimen container is to be done at the bedside of the patient to avoid errors.

A registered nurse is teaching a group of student nurses about legal guidelines for the effective recording of a patient's data on a handwritten paper document. Which statement by a student nurse needs correction?

The nurse should not leave blank spaces while recording the patient's health information, because another person may add incorrect information in the blank spaces. The nurse should draw a horizontal line in the space with his or her signature at the end to avoid this potential issue. The nurse should avoid using generalized, empty phrases such as "had a good day," which do not provide any information. Errors should not be erased, because doing so may indicate that the nurse is hiding some evidence. Errors should be scratched out with a single line, and the nurse should sign and date it. Black ink is more legible when records are photocopied or scanned, and illegible entries may lead to misinterpretations. `

Which nursing activities are performed during safety planning for a patient?

The nursing activities during the safety planning phase for a patient include consulting with occupational and physical therapists for assistive devices and selecting interventions that will improve the safety of the patient's home environment. *When assessing the patient's safety, the nurse should identify the patient's perceptions of safety needs and risks. According to the critical thinking model for safety, determining the impact of the underlying illness on the patient's safety, and the effect of environmental influence on the patient's safety are the nursing activities related to the assessing phase.

While reviewing the laboratory blood reports of a male patient, the nurse finds that his iron level is 60 mcg/mL. What does the nurse suspect from this finding?

The patient has a chronic infection. *The normal range of iron level is from 80 to 180 mcg/mL for men and 60 to 160 mcg/mL for women. Iron levels decrease due to infections. Therefore, a male patient with a 60 mcg/mL iron level indicates a chronic infection.

Which instrument used by the nurse requires surface disinfection? - Endoscope - Cardiac catheter - Urinary catheter - Blood pressure cuff

There are two types of disinfection: disinfection of surfaces and high-level disinfection. Noncritical items such as blood pressure cuffs require a surface disinfection. Semi-critical items such as endoscopes require high-level disinfection. Critical items such as cardiac and urinary catheters require sterilization.

On the nursing unit, you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system?

This is an example of an electronic health record. The electronic health record is an electronic record of patient health information generated whenever a patient accesses medical care in any healthcare delivery setting. In this system, you are able to access information about the patient during the current hospitalization and from four previous times when the patient accessed care. Information technology and personal health information are not a type of record system. The administration information systems support the effective use of information technology.

The nurse is dressing the surgical wound of a patient in the intensive care unit of a hospital. Which skill should the nurse develop to ensure full dexterity while using gloved hands after applying a sterile gown? - The nurse should use the gloved, nondominant hand to pull on the other glove. - The nurse should wear gloves with fingers fully extended into them. - The nurse should pick up a glove for the nondominant hand by grasping the folded cuff of the gown. - The nurse should open the inner sterile glove package with hands covered by gown sleeves.

To ensure full dexterity while performing the task with gloved hands, the nurse should wear the gloves with fingers completely extended into them. The nurse cannot dress the wound properly when the fingers do not extend into the gloves. *The nurse should use the gloved, nondominant hand to pull on the other glove in order to maintain sterility, but this does not ensure full dexterity. To ensure sterility, the nurse picks up a glove for the nondominant hand by grasping the gown's folded cuff. The nurse should open the inner, sterile glove package with hands covered by gown sleeves to ensure sterility and avoid contamination.

Which disease can be transmitted when a nurse is drawing blood from a patient with an infection? - Chickenpox - Scarlet fever - Tuberculosis - Hepatitis B virus

Vehicles such as blood may transmit the hepatitis B virus. *Chickenpox, scarlet fever, and tuberculosis can be transmitted through the air or droplet nuclei.

A surgeon applies a sterile gown before a procedure. Which actions should the circulating nurse perform? Select all that apply. - Covering the sterile flap by touching it - Touching the inside of the gown towards the body - Opening the sterile pack containing the sterile gown - Tying the back of the gown securely at the neck and waist - Preparing the glove package by peeling the outer wrapper

While a surgeon is applying a sterile gown, the circulating nurse should tie the back of the surgeon's gown securely at the neck and waist. The circulating nurse should prepare the glove package by peeling the outer wrapper. The circulating nurse can open the sterile pack containing the sterile gown. The circulating nurse should not touch the sterile flap, because it may get contaminated. While applying a sterile gown, the surgeon should keep the inside of the gown towards the body.