EBP-Safety-PCC
Which procedure reduces the potential for infection primarily by addressing the portal of entry?
Wearing gloves when contact with blood or body fluids is anticipated
The nurse reviews discharge instructions with a client who underwent a left groin cardiac catheterization 8 hours ago. Which instructions should the nurse include?
"Do not bend at the waist, strain, or lift heavy objects for the next 24 hours."
Which statement best indicates that a client understands how to administer his own insulin injections?
"I wrote down the steps in case I forget what to do."
The maximum transfusion time for a unit of packed red blood cells (RBCs) is
4 hours.
What consideration should the nurse keep in mind regarding the use of side rails for a patient who is confused?
A person of small stature is at increased risk for injury from entrapment.
The nurse is providing discharge instructions to a client who has nasal packing in place following nasal surgery. Which discharge instructions would be most appropriate for the client?
Avoid sports activities for 6 weeks.
A 10-year-old male presents with low-grade fever, nausea, and abdominal pain. The nurse examining him suspects appendicitis and checks for rebound tenderness in what quadrant?
lower right
A client is being treated for trichomoniasis. The client has received instructions about the prescribed drug therapy. The nurse determines that the client needs additional teaching when she states which of the following?
"My partner will not need any treatment."
A 56-year-old client meets with the nurse for education about a recently diagnosed atrial fibrillation. The client verbalizes concerns about being away from work too long and doubts about the necessity of having blood tests every week, as the client has no symptoms. Which is the best motivational statement by the nurse for this client?
"The medicine and blood work can help prevent blood clots, which can lead to strokes. What do you know about warfarin therapy?"
When discussing emergency preparedness with a group of first responders, what information would be important to includeabout preparation for a terrorist attack?
BLI is a serious consequence following detonation of an explosive device.
The mother of a pediatric client being discharged confides to the nurse that her husband is abusive and she is afraid to return home. What is the nurse's most appropriate action?
coordinate with the case manager to make a safe discharge plan.
The nurse is caring for a client who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on the client
returning to the nursing unit with two chest tubes.
Based on the statistics for the leading cause of hospital admission for trauma in older adults, what would be the nurse's priority intervention to prevent trauma when caring for older adults in a nursing home?
Making sure patient rooms are decluttered.
After a person experiences a closure of the epiphyses, which statement is true
No further increase in bone length occurs.
Nurses in an ICU noticed that their clients required fewer interventions for pain when the ICU was quiet. They then asked a researcher to design a study about the effects of noise on the pain levels of hospitalized clients. How does this demonstrate the ultimate goal of expanding the nursing body of knowledge?
Nursing research helps improve ways to promote and maintain health.
A nurse is using the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model PET as a clinical decision-making tool when delivering care to patients. Which steps reflect the intended use of this tool? Select all that apply.
A nurse recruits an interprofessional team to develop and refine an EBP question. A nurse searches the Internet to find the latest treatments for type 2 diabetes. A nurse questions the protocol for assessing postoperative patients in the ICU.
The nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply.
A patient who has already fallen twice A patient who experiences postural hypotension A 70-year-old patient who is transferred to long-term care
A nurse is assessing the following children. Which child would the nurse identify as having the greatest risk for choking and suffocating?
A toddler playing with his 9-year-old brother's construction set
When conducting quantitative research, the researcher collects information to support a hypothesis. This information would be identified as:
Data
Low levels of the neurotransmitter serotonin lead to which of the following disease processes?
Depression
A client is being scheduled for a stress test. The client is unable to exercise during the test. The nurse would include information about which medication used for pharmacologic stress testing
Dipyridamole
A nursing instructor is instructing a group of new nursing students. The instructor reviews that surgical asepsis will be used for which procedure?
I.V. catheter insertion
An older resident who is disoriented likes to wander the halls of his long-term care facility. Which action would be mostappropriate for the nurse to use as an alternative to restraints?
Identifying his door with his picture and a balloon
The nurse is conducting a community education program on colorectal cancer. Which statement should the nurse include in the program?
It is the third most common cancer in the United States.
Which cranial nerve is responsible for muscles that move the eye and lids?
Oculomotor
While discussing home safety with the nurse, a patient admits that she always smokes a cigarette in bed before falling asleep at night. Which nursing diagnosis would be the priority for this patient?
Risk for suffocation related to unfamiliarity with fire prevention guidelines
Which medication system allows for client independence?
Self-administered medication system
The client vomits during the surgical procedure. The best action by the nurse is:
Suction the client to remove saliva and gastric secretions.
A nurse is using general systems theory to describe the role of nursing to provide health promotion and patient teaching. Which statements reflect key points of this theory? Select all that apply.
The whole system is always greater than the sum of its parts. Boundaries separate systems from each other and their environments. To survive, open systems maintain balance through feedback.
Which pregnant woman should consult with her obstetric provider before continuing an exercise program?
a 33-year-old G5 P1 with a history of incompetent cervix
A nurse who specializes in maternal and child health care performs many varied functions in diverse settings over the course of a year. Which action would be outside the nurse's scope of practice?
assist in the treatment and recovery of a woman with ovarian cancer.
A nurse studies the culture of Native Alaskans to determine how their diet affects their overall state of health. Which method of qualitative research is the nurse using?
Ethnography
A nurse orients an older adult to the safety features in her hospital room. What is a priority component of this admission routine?
Explain how to operate the call bell.
A student nurse interacting with patients on a cardiac unit recognizes the four concepts in nursing theory that determine nursing practice. Of these four, which is most important?
Person
The nurse cares for a client of a different cultural background. What is the best way for the nurse to provide culturally competent care to the client?
Plan and implement care in a way that is sensitive to the needs of the client.
The nurse is working in the labor and birth unit when a client with active herpes simplex virus-Type 2 (HSV-2) appears in active labor. Which adjustment in the plan of care is anticipated?
Prepare the client for a cesarean section.
A nurse manager schedules a clinic for the staff to address common nursing interventions used in the facility and to explore how they can be performed more efficiently and effectively. The nurse manager's actions to change clinical practice are an example of a situation described by which nursing theory?
Prescriptive theory
A nurse is teaching parents in a parenting class about the use of car seats and restraints for infants and children. Which information is accurate and should be included in the teaching plan?
Booster seats should be used for children until they are 4′9″ tall and weigh between 80 and 100 lb.
The nurse teaches the client that reducing the viral load will have what effect?
Longer survival
A charge nurse meets with staff to outline a plan to provide transcultural nursing care for patients in their health care facility. Which theorist promoted this type of caring as the central theme of nursing care, knowledge, and practice?
Madeline Leininger
A nurse is caring for a 5-year-old child with end-stage acquired immunodeficiency syndrome (AIDS). The child confides that the child is ready to go to heaven and see Grandpa. The nurse knows that the child's parents aren't comfortable with the idea of discontinuing treatment. What should the nurse do?
Talk with the parents about the dying process and make the parents aware of what the child has confided.
What is the primary purpose associated with the use of the nursing process related to the implementation of medication therapy?
That holistic, evidence-informed care is given
The nurse is reviewing the medication administration record of the client. Which medication would lead the nurse to suspect that the client is suffering from an acute attack of gout?
colchicine
After an instructor has posted assignments, a person claiming to be a nursing student arrives on a unit and asks a nurse for access to the medication records of a client to whom the student nurse has been assigned. The student's only identification (ID) is a laboratory coat with the school's name on it. What is the nurse's most appropriate response?
Ask the student to provide a photo ID for comparison with the names on the assignment sheet.
a nurse provides evening care for a client wearing a continuous telemetry monitor. While the nurse is giving the client a back rub, the client 's monitor alarm sounds and the nurse notes a flat line on the bedside monitor system. What is the nurse's first response?
Assess the client and monitor leads.
A nurse working in a pediatrician's office receives calls from parents whose children have ingested toxins. What would be the nurse's best response?
Call the PCC immediately before attempting any home remedy.
A nurse is formulating a clinical question in PICOT format. What does the letter Prepresent?
Explicit descriptions of the population of interest
Which nursing intervention would best demonstrate evidence-based practice in maternal-child health care?
Family-centered pediatric care
A nurse is preparing to assess an older adult patient. Which approach would the nurse most likely use?
Functional assessment
A school nurse is teaching parents about home safety and fires. What information would be accurate to include in the teaching plan? Select all that apply.
Most people who die in fires die of smoke inhalation. Fire-related injury and death have declined due to the availability and use of smoke alarms. Fires are more likely to occur in homes without electricity or gas.
A child in the clinic has a fever and reports a sore neck. Upon assessment the nurse finds a swollen parotid gland. The nurse suspects which infectious disease?
Mumps
A nurse is conducting quantitative research to examine the effects of following nursing protocols in the emergency department (ED) on patient outcomes. This is also known as what type of research?
Quasi-experimental
A nurse is providing disaster care in an event that is known to involve gamma radiation. When admitting victims of the disaster, what should the nurse do to best reduce victims' risks of injury?
Remove victims' clothing and have them wash themselves thoroughly.
When a fire occurs in a patient's room, what would be the nurse's priority action?
Rescue the patient.
A client has been admitted with type 2 diabetes mellitus and asks to have the local medicine man come and help decide what traditional aboriginal medicines could help. What are the appropriate nursing interventions based on this client's request?
Suggest that the client inform and discuss with the interprofessional team how traditional therapies could be integrated into the plan of care.
The nurse is caring for the client in the preoperative period and documenting rationale for a palliative surgical procedure. Which rationale is most appropriate?
The client and physician are focusing on symptom relief not a cure.
A client has been diagnosed with atrial fibrillation and has been prescribed warfarin therapy. What should the nurse prioritize when providing health education to the client?
The need to have regular blood levels drawn
The Joint Commission issues guidelines regarding the use of restraints. In which case is a restraint properly used?
The nurse ensures that two fingers can be inserted between the restraint and patient's ankle.
A nurse is filing a safety event report for a confused patient who fell when getting out of bed. What action is performed appropriately?
The nurse records the circumstances and effect on the patient in the medical record.
A client receives a daily injection of glargine insulin at 7:00 a.m. When should the nurse monitor this client for a hypoglycemic reaction?
This insulin has no peak action and does not cause a hypoglycemic reaction.
The nurse is caring for a 10-year-old male in a pediatric clinic with presenting symptoms of small circular patches of hair loss on the scalp. Which skin condition does the child most likely have?
Tinea capitis
A student nurse asks an experienced nurse why it is necessary to change the patient's bed every day. The nurse answers: "I guess we have just always done it that way." This answer is an example of what type of knowledge?
Traditional knowledge
A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk?
Use the sealed and chilled milk within 24 hours.
The nurse is caring for a client with muscular dystrophy who is confined to bed. The client develops a pressure ulcer on the sacrum. The nurse documents the pressure ulcer as a(n)
secondary condition.
