FUNDA 2: Safety/Infection Control

The emergency department nurse receives report on 4 clients. Which client will the nurse prioritize for placement in an isolation room? 1. 4-year-old diagnosed with scabies who has red burrows and bumps along the neckline and inner elbows 2. 7-year-old diagnosed with measles who has a fever, conjunctivitis, cough, and maculopapular rash 3. 12-year-old with a positive rapid influenza test who has a fever, cough, and runny nose 4. 14-year-old with 4-inch wound on inner aspect of thigh with a positive culture for methicillin-resistant Staphylococcus aureus

2

A client with advanced Alzheimer's dementia is admitted to a skilled nursing facility for delirium. The nurse determines that the client can bear weight partially. Which would be the most appropriate method for the nurse to use to transfer this client safely? 1. 1-person stand and pivot with a gait belt and walker 2. 2-person full-body sling lift 3. 2-person motorized standing-assist lift 4. 2-person stand and pivot with a gait belt and walker

2

The school nurse is speaking with the parent of a fourth grade student about a bed bug that was found on the child's sweater. The parent confirms that their home is infested but that the issue is being resolved. Which is the best action by the nurse? 1. Instruct the parent to launder the child's clothing and store it in tightly sealed plastic bags 2. Instruct the teacher of the child's classroom to use an insecticide spray 3. Send letters home to all of the children's parents informing them about the finding 4. Send the child home and prohibit school attendance until the infestation has been resolved

1

The registered nurse walks into the client's inpatient room and sees a fire in the wastebasket. The nurse should take which action first? 1. Activate the fire alarm 2. Close the door 3. Pour water on the fire 4. Use a fire extinguisher

1

A client in the mental health unit picks up a fire extinguisher and throws it at a nurse standing by the nurses' station. What is the most important intervention by the nurse? 1. Facilitate immediate removal of people from the area 2. Inform the client that the client cannot act that way 3. Pull the fire alarm to get additional immediate help 4. State that the nurse can see the client is upset

1

A comatose client in the intensive care unit has an indwelling urinary catheter. Which action(s) should the nurse implement to reduce the incidence of catheter-associated urinary tract infections (UTIs)? Select all that apply. 1. Cleanse periurethral area with antiseptics every shift 2. Ensure each client has a separate container to empty collection bag 3. Keep catheter bag below the level of the bladder 4. Routinely irrigate the catheter with antimicrobial solution 5. Use sterile technique when collecting a urine specimen

2,3,5

A client with a tracheostomy is alert and oriented and able to tolerate oral intake. Which action would be appropriate to reduce the client's risk of aspiration pneumonia? 1. Fully inflate the cuff before feeding 2. Have the client sit in an upright position with the neck hyperextended 3. Partially or fully deflate the cuff 4. Provide a modified diet of pureed foods

3

Funda Safetyiinfection #50 - Drag and Drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348621

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Funda Safetyiinfection #79 - Drag and Drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348623

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Which equipment warnings indicate a clinical issue with a client and not an issue with the programming of the equipment or a mechanical failure? Select all that apply. 1. The glucometer displays "HI" from a blood specimen of a client with diabetic ketoacidosis 2. The intravenous infusion pump display lights up and sounds an alarm for a few seconds when turned on 3. The patient-controlled analgesia (PCA) pump indicates it is unable to read the barcode on the medication vial 4. The pulse oximeter does not register a heart rate pulsation or reading in a client with peripheral vascular disease 5. The ventilator high pressure alarm sounds for a client intubated for acute respiratory distress syndrome

1,4,5

Which guiding principle is suitable for dealing with a disaster scenario involving radiation contamination? 1. Assess for copious secretions to determine exposure 2. Assist the victims farthest from the source first 3. Assist the victims with the most severe symptoms first 4. Monitor for diplopia to determine extent of exposure

2

The nurse is caring for a client with bacterial meningitis identified as Neisseria meningitidis. Which personal protection is mandatory for the nurse when performing the morning assessment? Select all that apply. 1. Face shield 2. Gown 3. Hand washing 4. N95 respirator 5. Surgical mask

3,5

There has been a large-scale community disaster and clients must be roomed together at the hospital. Who are appropriate roommates in light of infection risk principles? Select all that apply. 1. A client diagnosed with varicella and a client with pertussis 2. A client placed in an airborne infection isolation room (AIIR) and a client with heart failure 3. A client receiving chemotherapy and a client with chronic obstructive pulmonary disease (COPD) coughing yellow sputum 4. A client with pelvic inflammatory disease (PID) and a client with coffee ground emesis 5. Two clients diagnosed with tuberculosis

4,5

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Funda Safetyiinfection #46 - Drag and Drop http://author.udutu.com/myudutu/preview/previewcourse.aspx?CourseID=137491&ScreenID=4348620

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The nurse is caring for a client on droplet precautions who has a prescription for a CT scan. When transporting the client to radiology, the nurse should ensure that the transporter uses protective equipment correctly to reduce the environmental spread of infection when the client is outside the room. Which instruction should the nurse give the transporter? 1. Have the client wear a mask 2. Have the client wear gloves 3. Wear a mask 4. Wear an isolation gown

1

The nurse is caring for a client who develops Clostridium difficile colitis after multiple days of antibiotic therapy. Which infection control measures are appropriate to implement? Select all that apply. 1. Disinfect surfaces with diluted bleach solution 2. Hand hygiene with alcohol-based hand rub 3. Wear a face mask 4. Wear a protective gown 5. Wear nonsterile gloves

1,4,5

The nurse has unlicensed assistive personnel (LJAP) caring for a client with an acute attack of Meniere disease. Which action by the UAP will require follow-up by the nurse? 1. Assist the client in ambulating to the bathroom 2. Dim the room lights 3. Place the bed in low position with all side rails up 4. Turn off the television

3

The charge nurse on the orthopedic unit has 4 semiprivate room beds available. Which room should the nurse assign to a client being transferred from the post anesthesia recovery unit following a total knee replacement? 1. Room 1 - client in skeletal traction following a fracture of the femur, who has erythema at the pin sites 2. Room 2 - client with cellulitis and osteomyelitis following blunt trauma of the tibia 3. Room 3 - client with compartment syndrome following a crush injury, who is 1 day post fasciotomy 4. Room 4 - client with a long leg cast following open reduction of a fractured tibia

4

The nurse on the IV therapy team is making rounds in the intensive care unit on clients with central venous catheters. Which central line should be removed earliest to prevent infection? 1. Femoral line inserted in emergency department post cardiac arrest 48 hours ago 2. Internal jugular line inserted 6 days ago in operating room 3. Peripherally inserted central catheter line with one lumen occluded that was placed 2 weeks ago 4. Subclavian line with slight redness at anchor suture sites inserted in intensive care unit 72 hours ago

1

Which statements involve acceptable use of an abbreviation, symbol, or dose designation in documentation? Select all that apply. 1. "2 cm x 3 cm x 1 cm stage IIdecubitus noted on left shin." 2. "4.0 u SSRI administered to cover capillary glucose of 160 mg." 3. "Dose of .5 mg hydromorphone administered and the client feels 'better." 4. "Maalox 5 mL administered pc as requested for c/o heartburn." 5. "Spouse voiced understanding of home urinary catheterization QID."

1,4,5

A 2-year-old who swallowed an overdose of adult cough syrup is being discharged from the emergency department. The parent says to the nurse, "From now on, I'm going to store all medicines in my top dresser drawer." Which is the best response by the nurse? 1. "Can you lock your dresser drawer?" 2. "Make sure all of your medicines have childproof caps." 3. "That sounds like a safe plam" 4. "You need to keep an eye on your child at all times."

1

A client has a leg immobilizer applied and leaves the emergency department with crutches. Which instructions by the graduate nurse require the nursing preceptor to intervene? 1. Hold 1 crutch in each hand when standing up from a chair 2. Hold both crutches on the same side when standing up from a chair 3. Touch the back of legs to the seat of the chair when preparing to sit 4. Use an armrest or seat for assistance when lowering body into a chair

1

A client is able to partially bear weight and follow the nurse's instructions. Which would be the most appropriate method for the nurse to use to safety transfer this client? 1. 1-person stand and pivot with gait belt and walker 2. 1-person standby assist with walker 3. 2-person motorized stand-assist lift 4. 2-person stand and pivot with gait belt and walker

1

The charge nurse on a pediatric unit recognizes that it is acceptable for which pair of clients to be assigned to a semi-private room? 1. 4-year-old girl in Buck traction and 5-year-old boy post laparoscopic appendectomy 2. 6-year-old girl with varicella and 7-year-old girl with measles 3. 9-month-old boy with rotavirus infection and 8-month-old boy with salmonella infection 4. 14-year-old girl with sickle cell anemia and 1 3-year-old girl with periorbital cellulitis

1

The nurse cares for a confused client who continues to pull at the intravenous (IV) catheter on the left forearm despite frequent instructions not to do so. What is the nurse's next action? 1. Apply a gauze wrap and elastic stockinette around the IV site 2. Apply a mitt on the right hand 3. Apply a soft wrist restraint on the right wrist 4. Apply an arm board to the left arm

1

The nurse is administering a pink pill to a hospitalized medical-surgical client. The alert, oriented client says, "This is a pill I haven't seen before." What follow-up action should the nurse take next? 1. Check the health care provider's prescription in the medical record 2. Explain that the health care provider has prescribed the medication 3. Look up the medication in the pharmacology reference 4. Teach the client about the purpose of the medication

1

A client with suspected foot osteomyelitis is scheduled for magnetic resonance imaging (MRI). Which assessment findings should the nurse notify the health care provider (HCP) about before the test? Select all that apply. 1. Cardiac pacemaker 2. Colostomy 3. Retained metal foreign body in eye 4. Total hip replacement 5. Transdermal testosterone patch

1,3,4

The camp nurse conducts a class for incoming summer counselors on prevention of tick bites and associated complications. Which instructions should the nurse include? Select all that apply. 1. Avoid hiking through tall grass and wooded areas 2. Cover ticks found on skin with petroleum jelly 3. Report bull's-eye-shaped rash or flu-like symptoms 4. Use tick repellent on skin and clothing 5. Wear dark-colored clothing while hiking

1,3,4

Which measures will help prevent falls in the elderly clients of a long-term care facility? Select all that apply. 1. Exercise programs 2. Good room lighting 3. Handrails in stairwell 4. Smooth-soled shoes 5. Staff hourly rounds

1,2,3,5

The charge nurse is planning assignments for the day. Which clients will require the nursing staff to institute contact precautions? Select all that apply. 1. 38-year-old with methicillin-resistant Staphylococcus aureus 2. 42-year-old with Clostridium difficile diarrhea 3. 69-year-old with pertussis infection 4. 72-year-old with vancomycin-resistant Enterococcus 5. 80-year-old with influenza

1,2,4

The nurse caring for a client diagnosed with HIV uses which infection prevention and control measures? Select all that apply. 1. Gloves when contact with body fluids is anticipated 2. Gloves when starting an intravenous line 3. Gown, gloves, face shield, and goggles for every client encounter 4. Hand hygiene before and after providing client care 5. N95 respiratory mask and face shield

1,2,4

The nurse is preparing to administer medications to the clients. Which client attributes are acceptable for use as client identifiers? Select all that apply. 1. Day, month, and year of birth 2. Last name 3. Medical record number 4. Primary care provider (PCP) 5. Room number

1,3

A client who is intubated and on mechanical ventilation is receiving continuous enteral tube feedings at 30 ml_/hr via a small-bore nasogastric tube. Which actions should the nurse take to prevent aspiration in this client? Select all that apply. 1. Assess abdominal distension every 4 hours 2. Check gastric residual every 12 hours 3. Keep head of the bed at >30 degrees 4. Maintain endotracheal cuff pressure 5. Use caution when administering sedatives

1,3,4,5

A nurse in the surgical admitting unit is preparing a client for elective coronary artery bypass surgery. Which statement by the client should the nurse report immediately to the health care provider (HCP)? 1. "I haven't had anything to eat or drink since 8 PM yesterday." 2. "I took my prasugrel this morning with just a tiny sip of water." 3. "I'm really nervous about this surgery" 4. "It always takes several attempts to start my IV"

2

A nurse is caring for a homeless client who is moderately malnourished and suffering from pneumonia. The client needs a peripheral IV line for fluid administration. Which IV site should the nurse select to reduce the risk for infection? 1. Antecubital fossa 2. Dorsal surface of hand 3. Dorsum of foot 4. Lateral surface of wrist

2

The charge nurse is notified that a client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client? 1. A private room with contact and droplet precautions 2. A private room with negative airflow and contact and airborne precautions 3. A private room with positive airflow and airborne precautions 4. A semi-private 2-bed room with standard precautions

2

A client with Ebola was just admitted to the unit. Which actions by the nurse would represent appropriate care of this client? Select all that apply. 1. Ensuring the client wears an N95 respirator at all times 2. Keeping the door of the client's room closed at all times 3. Maintaining a log of everyone in and out of the client's room 4. Removing both pairs of gloves before removing gown and mask 5. Restricting visitors from entering the client's room

2,3,5

A client is being admitted to the health care facility with a new diagnosis of Clostridium difficile colitis. Which elements of infectious disease precautions are necessary when providing routine care for this client? Select all that apply. 1. Alcohol-based sanitizers for hand cleaning 2. Client in single-room (private) isolation 3. Nurse using N95 respirator 4. Nurse using sterile gloves 5. Nurse using surgical mask 6. Nurse wearing disposable gown

2,6

A 3-month-old infant is treated in the emergency department for a spiral femur fracture. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action? 1. Document a description of the injury 2. Question the mother about where the infant sleeps 3. Report the injury per facility protocol 4. Separate the mother from the infant

3

A home health nurse is teaching the spouse of an elderly client who experienced a stroke ways of reducing risks for falls in the home. Which suggestion by the spouse would be the most effective plan to prevent falls? 1. Have a respite caregiver come once a week to stay with the client so the spouse can go shopping 2. Purchase a walker for the client to use when ambulating around the home 3. Remove all area rugs and install grab bars in the bathroom 4. Take the client for an annual eye exam and new glasses

3

A nurse is caring for a group of clients on a medical surgical unit. Which client is most at risk for contracting a nosocomial infection? 1. 51 -year-old client who received a permanent pacemaker 48 hours ago 2. 60-year-old client who had a myocardial infarction 24 hours ago 3. 74-year-old client with stroke and an indwelling urinary catheter for 3 days 4. 75-year-old client with dementia and dehydration who is on IV fluids

3

The nurse working in an intensive care unit cares for a client with a left triple lumen subclavian central venous catheter (CVC). The nurse should call the primary health care provider (HCP) for clarification prior to implementation when recognizing that which prescription is an error? 1. Administer intravenous (IV) total parenteral nutrition (TPN) at 50 mL/hr 2. Change occlusive central line dressing every 7 days 3. Flush unused lumens of the CVC with 1000 units heparin every 12 hours 4. Use distal port of CVC to monitor central venous pressure (CVP

3

The public health nurse conducts a program at the community senior citizen center about preventing falls at home. Which statement made by a participant indicates that further education is needed? 1. "I bought a new nightlight for the hallway to the bathroom." 2. "I feel so much more secure wearing my electronic fall alert device." 3. "I walk in my stockings at home because it helps to relieve my bunion pain." 4. "My daughter helped me secure the small, thin rug in my kitchen with strong tape."

3

The nurse recognizes that which factors place a client at increased risk for falls? Select all that apply. 1. Age of 50 2. Diagnosis of ovarian cancer 3. Lying pulse 80/min, standing pulse 11 0/min 4. Osteoarthritis of knees 5. Takes carbidopa/levodopa 6. Uses a cane to ambulate

3,4,5,6

A client with acute ST-elevation myocardial infarction intends to leave the hospital now against medical advice (AMA) regardless of what is recommended. The client is determined to be competent to make personal decisions. Which of the following is the most important for the nurse to do before the client leaves the building? 1. Insist the client sign the AMA form 2. Provide the client with a copy of hospital results 3. Reassure that the client can return later 4. Remove the intravenous catheter

4

A community mental health nurse is a member of a mobile crisis team providing services to victims of a category 4 hurricane. Of these strategies, which would be the priorityaction for the team to utilize in reaching those who need mental health services? 1. Contacting other social service agencies 2. Knocking on doors 3. Putting up flyers 4. Reporting in to the local command center

4

An unconscious client is brought to the emergency department by the paramedics after being hit by a car. An emergency craniotomy is required. The client has no identification. What action should be taken next? 1. Contact the national database to see if the client has a healthcare proxy 2. Contact the police to help identify the client and locate family members 3. Obtain a court order for the client's surgical procedure 4. Transport the client to the operating room under implied consent

4

The charge nurse is preparing for the admission of an elderly client with delirium and agitation associated with urinary tract infection. To promote client safety, which intervention is most important for the charge nurse to implement? 1. A bed near the nursing station 2. Four-point leather restraints 3. Minimizing environmental stimuli 4.One-on-one supervision from a sitter

4

Which client is most at risk for hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA)? 1. 5-year-old student athlete in the emergency department with a fractured femur 2. 46-year-old with a large abdominal incision and 2 peripheral IV lines 3. 72-year-old who received a permanent pacemaker 24 hours ago 4. 80-year-old with chronic obstructive pulmonary disease (COPD) who is on a ventilator

4

A home health nurse is supervising a home health aide who is changing the dressing for a client with a chronic heel wound. Which actions by the aide indicate adherence to appropriate infection control procedures? Select all that apply. 1. Open a sterile container of 4 x 4's using the outermost corner to peel back the cover 2. Pull glove off over the soiled dressing to encase it before disposal 3. Save unused sterile 4 x 4's by taping original package shut for the next dressing change 4. Wash hands prior to putting on gloves and after removing them 5. Wrap soiled dressing in paper towels before disposing of it in the trash can

1.2.4

The male client had a hemicolectomy. The client is refusing to wear the prescribed sequential compression devices (SCDs). What is most important for the nurse to communicate to the client? 1. An appropriate form must be signed, verifying refusal 2. Complications, including death, could result 3. The client will be billed for the equipment regardless 4. The surgeon will be informed of the refusal

2

The nurse answers a call light on a client not assigned to the nurse. The client, who was just admitted from the emergency department, requests a cup of coffee. What is the appropriate Intervention? 1. Allow a family member to bring the client a cup of coffee from the cafeteria 2. Ask the client to wait until the health care provider's (HCP's) prescriptions can be verified 3. Delegate the task to the unlicensed assistive personnel (UAP) assigned to the client 4. Suggest water instead until admission assessment can be completed

2

The nurse finds a client on the floor in the client's room. Based on the documentation shown in the exhibit, the nurse made an incorrect entry in the client's medical record at what time? Click on the exhibit button for additional information. Exhibit: 1700 Found client lying on floor next to bed. Client states, "l fell out of bed while reaching for my eyeglasses and hit my head on the bedside table." Client is alert and oriented to time, place, person, and situation. Denies pain, dizziness, or nausea No visible injuries.Assisted back to bed. Neurological vital signs within normal limits (see assessment flow sheet). Client instructed to use call bell for assistance. Will continue to monitor._________________RN 1710 Health care provider (HCP) notified of fall. Prescribed CT of head STAT. ___________RN 1740 No change in neurologic status.Client to CT via gurney. Report filed per policy. _____________RN 1810 Client returned from CT No change in neurologic status. Reinforced use of call bell, and client demonstrated understanding. Will continue to monitor. _____________RN 1. 1700 2. 1710 3. 1740 4. 1810

3

A graduate nurse is caring for a client with a triple-lumen peripherally inserted central catheter in the right arm. Which actions by the graduate nurse indicate that more education is needed? Select all that apply. 1. Flushing the line before and after each medication administration 2. Pausing the parenteral nutrition prior to drawing blood from a different port 3. Reinforcing a torn peripherally inserted central catheter line dressing with tape 4. Scrubbing the port with alcohol for 5 seconds before use 5. Taking the client's blood pressure in the left arm

3,4

The nurse is caring for a client with active pulmonary tuberculosis. Which elements of infectious disease precautions are mandatory for the nurse when providing routine care? Select all that apply. 1. Gown 2. Goggles or face shield 3. Hand washing 4. N95 particulate respirator 5. Surgical mask

3,4

The nurse in the oral surgery clinic reviews a client's medical record prior to surgery. Which will the nurse immediately report to the oral surgeon? Select all that apply. 1. Client is on a calorie-restricted diet for obesity 2. Creatinine is 1.3 mg/dL (115 ɥmol/L) 3. History of congenital heart disease 4. International Normalized Ratio of 2.5 5. Presence of prosthetic valve

3,4,5

The nurse is drawing a blood specimen from a client's central line. Identify the steps necessary to prevent transmission of infection while performing this procedure. Select all that apply. 1. Discard the first 6-10 mL of blood drawn from the line 2. Flush the line with sterile normal saline before and after collection 3. Perform hand hygiene 4. Place the specimen in a biohazard bag 5. Scrub the catheter hub with antiseptic prior to use

3,4,5

The charge nurse on the medical surgical unit must assign a room for an immediate post-operative nephrectomy client. Which room assignment is the best option for this client? 1. Room 1 - Client with diabetes mellitus (DM) and chronic kidney disease (CKD) who is on hemodialysis and has a serum glucose level of 265 mg/dL 2. Room 2 - Client with chronic HIV infection and overwhelming fatigue who has a CD4+ cell count of 200/mm3 3. Room 3 - Client with cellulitis of the leg due to a spider bite who has a white blood cell (WBC) count of 13,000/mm3 4. Room 4 - Client with severe epistaxis due to a traumatic nasal fracture who has a platelet count of 85,000/mm3

4

The health care provider writes a prescription for hydromorphone 10 mg intravenous push every 2 hours prn for the post-operative client. The usual recommended dose is 0.2-1 mg every 2-3 hours prn. What action should the nurse initially take? 1. Administer the medication and monitor client frequently 2. Ask a nursing colleague if this drug amount is used 3. Check hydromorphone dose that the client had previously 4. Question the prescription with the prescriber

4

The nurse cares for a child with bed bug bites. Which parent statement indicates that further teaching is required? 1. "I need to have the entire house treated by pest control to ensure the bed bugs are gone." 2. "I should concentrate on alleviating scratching as it can cause further complications." 3. "My other family members and pets are at risk of bed bug bites." 4. "This must have happened because I did not wash the bed sheets this week."

4

A female nurse in the intensive care unit is caring for a client who is intubated and has subclavian central venous access. Which nursing intervention is most important to prevent the spread of infection to this client? 1. Frequent hand hygiene 2. No artificial nails 3. Use of chlorhexidine bath wipes 4. Wearing personal protective equipment

1

A student nurse performs the morning assessment and obtains a urine specimen from a client with methicillin-resistant Staphylococcus aureus (MRSA) who is on contact precautions. The registered nurse intervenes when the student performs which action? 1. Cleans the disposable stethoscope with chlorhexidine solution before use with another client 2. Removes the urine specimen cup from the room in a sealed biohazard bag 3. Scrubs the Foley catheter collection port with alcohol for 15 seconds before withdrawing a urine specimen 4. Uses an alcohol-based hand antiseptic solution after removing gloves

1

The nurse is caring for a client who weighs 450 1b (204.1 kg) 2 days after bariatric surgery. The client is pleasant, cooperative, and able to fully bear weight. What would be the most appropriate method for transferring this client safely? 1. 1-person safety standby with walker 2. 2-person full-body sling lift 3. 2-person standing-assist lift 4. 4-person full-body sling lift

1

The same-day surgery nurse performs the preoperative assessment for a client with a history of coronary artery disease scheduled for an elective laparoscopic cholecystectomy. Which statement made by the client is critical to report to the health care provider (HCP) before the surgery? 1. "I didn't take the clopidogrel pill for my heart yesterday or today." 2. "I know I should stop smoking completely, but at least I didn't have a cigarette yesterday or today." 3. "I stopped taking my gingko biloba 2 weeks ago even though it really helps relieve leg cramps when I walk." 4. "I stopped taking naproxen for my arthritis pain 1 week ago and have been taking acetaminophen instead.

1

A student nurse prepares to change a large wet-to-damp sterile wound dressing and uses a disposable moisture-proof sterile drape to set up the sterile field. The precepting nurse intervenes when the student performs which action? Holds the package 6" (15 cm) above the sterile field and drops the sterile gauze onto the field Opens the sterile gauze package with ungloved hands Places the sterile gauze dressings within 2" (5 cm) from the edge of the sterile drape Pours sterile normal saline solution (NSS) into a sterile basin from a bottle opened 30 hours ago

4

For which client is it most important for the nurse to provide teaching on ways to prevent the spread of the condition? 1. Client with eczema on upper torso 2. Client with oral candidiasis 3. Client with psoriasis on hands 4. Client with tinea corporis

4

A nurse on the telemetry unit is preparing client medications in the medication room at the nurse's station. The nurse should perform which actions to be consistent with client safety practices related to medication administration? Select all that apply. 1. Check laboratory values before administering anticoagulants 2. Compare medication, dosage, and route to prescription orders prior to administration 3. Discard any unlabeled medications 4. Open unit dose packages and place medications in a dispensing cup to take to the bedside 5. Wear gloves to handle unopened individual unit dose medication packages

1,2,3

What nursing care related to peripherally inserted IV catheters can reduce the incidence of catheter-related infections? Select all that apply. 1. Clean ports with 70% alcohol prior to accessing the catheter system 2. Prior to insertion, apply chlorhexidine in a back and forth motion with friction 3. Prior to insertion, use povidone-iodine to paint a circle and wipe excess with a sterile gauze 4. Replace or remove the catheter every 3 days 5. Shave excess hair over insertion site

1,2,4

A nurse is preparing a client for below-the-knee amputation surgery. Which actions should the nurse complete? Select all that apply. 1. Administer a preoperative IV antibiotic 2. Ensure that the correct limb to be amputated is marked appropriately 3. Place a red "no known allergies" bracelet on the client 4. Place operative permits in the clients chart 5. Replace the current 20G IV catheter with an 18G IV catheter

1,2,4,

The charge nurse in the cardiac intensive care unit responds to a client room where a resuscitation effort is in progress. The client's immediate family member refuses to leave the room. How should the charge nurse handle this situation? 1. Call security to escort the family member to the waiting room 2. Have the family member stand or sit in an area that is not in the staffs way 3. Inform the family member that relatives are not allowed in rooms during emergency situations 4. Let the family member stay and assign a staff person to explain what is happening

4

A client has been admitted with a catheter-associated, vancomycin-resistant enterococcal bacteremia. Which interventions should the nurse implement? Select all that apply. 1. Keep dedicated equipment for client 2. Perform hand hygiene before exiting the room 3. Place a "No Visitors" sign on the client's door 4. Wear a face mask when in the room 5. Wear an isolation gown when providing direct care

1,2,5

The nurse is caring for a client who was admitted to the hospital following a motor vehicle accident caused by the client's newly diagnosed seizure disorder. The health care provider (HCP) prescribes seizure precautions for the client. The nurse prepares to initiate which interventions? Select all that apply. 1. Apply pads to the side rails 2. Lift the side rails 3. Prepare to insert a urinary catheter 4. Remove all linen from the bed 5. Set up bedside suction

1,2,5

The nurse observes an ambulating client begin to experience a tonic-clonic seizure. Which nursing actions should be implemented immediately? Select all that apply. 1. Guide the client to the floor and gently cradle the head 2. Insert a tongue blade to prevent client from swallowing the tongue 3. Move objects that may cause injury away from the client 4. Physically restrain the client to prevent injury 5. Place the client in left lateral position 6. Remain with the client, observe, and record the seizure activity

1,3,5,6

The client is scheduled to have a cardiac catheterization. Which findings will cause the nurse to question the safety of the test proceeding? Select all that apply. 1. Allergy to shellfish 2. Elevated C-reactive protein 3. Prolonged PR interval on electrocardiogram 4. Serum creatinine of 2.5 mg/dL(221 ɥmol/L) 5. Took metformin today for type 2 diabetes

1,4,5

Which situations would require the nurse to obtain a prescription for physical restraints? Select all that apply. 1. Belt restraint used for a confused client who keeps trying to get out of bed but is on bed rest 2. Elbow restraints used temporarily for a toddler while drawing blood 3. Full padded side rails in the raised position for a client during a seizure 4. Long leg immobilizer used for a client with a fractured tibia 5. Soft ankle restraint to prevent bleeding at the femoral site following cardiac catheterization

1,5

The charge nurse must assign rooms to 4 clients who are scheduled for admission. Which client has the highest priorityfor a private room assignment? 1. Client who is a known IV drug abuser who has osteomyelitis of the arm and chronic hepatitis C 2. Client with chronic obstructive pulmonary disease who has a latent tuberculosis infection 3. Client with diabetes mellitus and HIV infection who is in diabetic ketoacidosis 4. Client with pneumonia who has a positive methicillin-resistant Staphylococcus aureus nose culture

4

The nurse applies soft wrists restraints to a confused, agitated client who is pulling at tubes and drains. What is the appropriate nursing action for obtaining the restraint prescription from the health care provider (HCP)? 1. Obtain a 24-hour, as-needed prescription to avoid calling the HCP during the night 2. Obtain a verbal or telephone prescription for restraints within 1 hour of initiation 3. Obtain a written prescription for restraints that is valid for 48 hours 4. Obtain a written prescription for restraints within 24 hours of initiation

2

The clinic nurse reinforces teaching to a client with systemic lupus erythematosus. Which instructions will the nurse include? Select all that apply. 1. Avoid annual influenza vaccination 2. Avoid situations that cause physical and emotional stress 3. Avoid sun exposure and ultraviolet light when possible 4. Notify the health care provider if you have fever 5. Use antibiotic soap to cleanse skin rashes

2,3,4

The health care provider has explained the risks and benefits of a planned surgical procedure and asks the registered nurse to obtain a signature on the consent form. Which would affect the legitimacy of the signature? Select all that apply. 1. Client is unsure of diet after the surgery 2. Client received hydromorphone 1 mg IV push 30 minutes ago 3. Client received ondansetron 8 mg IVP push 15 minutes ago 4. Fear of experiencing postoperative pain 5. Glasgow Coma Scale score (GCS) of 12

2,5

The charge nurse must assign a room for a client with dementia who was transferred from a long-term care facility and is scheduled for extensive surgical debridement of a stage 4 pressure ulcer. Which room assignment is the most appropriate for this client? 1. Room A: Client with multiple myeloma who is being treated with corticosteroids 2. Room B: Client with diabetes mellitus and osteomyelitis receiving IV antibiotics 3. Room C: Client with a gastrointestinal bleed who has a nasogastric tube set to low suction 4. Room D: Client with an acute migraine headache attack who requires V analgesia every 2 hours

3

The medical surgical nurse cares for a client who had a mediastinal tumor removed 2 days ago and reports difficulty breathing. The client becomes confused and restless, and respirations are 30/min. What is the nurse's next action? 1. Administer a dose of prescribed prn anti-anxiety medication 2. Call the health care provider who performed the surgery 3. Call the rapid response team 4. Place the client in the left lateral recovery position

3

The parent of a child treated for injuries consistent with suspected child abuse has been told that a report will be made to Child Protective Services (CPS). The parent says angrily to the nurse, "I don't know why this is being reported. I told the health care provider (HCP) that it was an accident". What is the best response by the nurse? 1. "A case worker from CPS will be visiting you in a few days. The case worker can explain it to you then." 2. "Did you ask the HCP why it is being reported?" 3. "Reporting your child's injuries is required by law. It is for your child's safety and protection" 4. "Your explanation of your child's injuries does not seem plausible."

3

Unlicensed assistive personnel report 4 situations to the registered nurse. Which situation warrants the nurse's intervention first? 1. Room 1: Client on a 24-hour urine collection had a specimen discarded by mistake 2. Room 2: Client and family request clergy to administer last rites 3. Room 3: Puncture-resistant sharps disposal container on the wall is full 4. Room 4: Client with diabetes mellitus has an 8 AM fingerstick glucose of 80 mg/dL (4.4 mmol/L)

3

The nurse is caring for a client who performs frequent self-urinary catheterizations. Which client assessments would indicate a potential for a latex allergy? Select all that apply. 1. History of angioedema with lisinopril 2. History of epilepsy 3. Known allergy to avocados and bananas 4. Known allergy to shellfish 5. Lip swelling when blowing up balloons

3,5

A 65-year-old client has been hospitalized for 2 weeks with diabetic gastroparesis. While preparing to administer the daily dose of IV metoclopramide to this client, the nurse assesses for which symptom that may indicate a serious adverse effect of this medication? 1. Bradycardia 2. Diarrhea 3. Frequent burping 4. Unusual movements

4

A client is scheduled for an elective laparoscopic prostatectomy in the morning. The nurse should notify the health care provider (HCP) about which assessment data as soon as possible before surgery? 1. Hemoglobin 15 g/dL (150 g/L), hematocrit 45% (0.45) 2. International Normalized Ratio (INR) 1.3 3. Platelet count 295,000/mm3 (295 x 109/L) 4. Temperature 100.4 F (38 C) with cough

4

The nurse is preparing to care for a client with acute myelogenous leukemia who is going through induction chemotherapy. The client's laboratory results are shown in the exhibit. Which intervention would be a priority for this client? Click on the exhibit button for additional information. Exhibit: Laboratory results White blood cells 1,100/mm3 (1.1 x 109/L) Absolute neutrophil count 400/ mm3 (0.4 x 109/L) Hemoglobin 82 g/dL (82 g/L) Platelets 78,000/mm3 (78 x 109/L) 1. Administer erythropoietin injection 2. Minimize venipunctures and avoid intramuscular injections 3. Place sequential compression devices (SCDs) to the legs 4. Provide a private room and neutropenic precautions

4

The nurse prepares to care for a client being admitted with a confirmed diagnosis of Middle East respiratory syndrome. Which personal protective equipment will the nurse use when providing care to the client? 1. Gloves and gown 2. Gloves and mask 3. Gown and N95 respirator 4. Gown, gloves, N95 respirator, and eye protection

4

The nurse should consider which of the following client reports as an indication of an allergic reaction? 1. "I can't eat broccoli or cabbage when I take my warfarin." 2. "I get a headache when using my nitroglycerine patch." 3. "My feet swell when I take felodipine.' 4. "My lips swell when I eat bananas or avocados."

4

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A new nurse attends a risk management class on the indications and legal implications of using chemical restraints to maintain client safety. Which prescription should the nurse question before administering? 1. Haloperidol for a client with a fall history who keeps getting out of bed without assistance 2. Lorazepam for a client who is in alcohol withdrawal and is extremely agitated 3. Olanzapine for a client with schizophrenia who is exhibiting violent behavior 4. Propofol for a client who is intubated and receiving mechanical ventilation

1

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take? 1. Have the client remove the existing dressing while the nurse prepares sterile supplies 2. Wear clean gloves for removal and application of a new dressing 3. Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing 4. Wear sterile gloves, gown, and goggles to remove the soiled existing dressing

3

The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching? 1. The axillary pads are torn and show signs of wear 2. The client has a 30-degree bend at the elbow when walking 3. The crutches and injured foot are moved simultaneously in a 3-point gait 4. There is a 3 finger-width space noted between the axilla and axillary pad

1

The nurse supervisor tells the psychiatric nurse to go to the telemetry unit ("float") as the unit is short staffed and has 2 clients with cardiac arrest. The nurse is not familiar with this client population and does not want to go. What is the best response by the psychiatric nurse? 1. Clarify the skills/knowledge that the nurse is able/unable to perform 2. Read the policy and procedure book for the unit before providing care 3. Refuse to go due to concerns about client safety 4. Tell the supervisor to send someone else instead

1

The nurse is caring for an agitated client with dementia who is pulling at the oxygen and V tubing. Less-restrictive measures were ineffective, so wrists restraints are now applied.Which actions are appropriate to protect the client from injury? Select all that apply. 1. Attach wrist restraint straps to the bed frame using a square knot 2. Keep the room lights on to provide stimulation and diversion 3. Place gauze pads under the restraints to avoid excessive pressure 4. Position the client supine to keep the wrist restraint straps taut 5. Release the restraints every 2 hours and determine the need for continued use

3,5

A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor? 1. Step behind client with arms around waist, squat using the quadriceps, and lower client to the floor 2. Step in front of client, brace knees and feet against the client's, and assist to the floor gently 3. Step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor 4. Step 12 inches behind the client, support under axillae, tighten back, and lower client to the floor

4

The nurse caring for a client with tuberculosis (TB) transports the client to the radiology department for a chest x-ray. The nurse ensures that the client uses which personal protective equipment when out of the negative-pressure room? 1. Isolation gown, surgical mask, goggles, and gloves 2. Isolation gown and surgical mask 3. N95 respirator mask 4. Surgical mask

4

The nurse in the intensive care unit (ICU) is giving unlicensed assistive personnel (UAP) directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus (MRSA). Which instructions would be most effective for reducing infection? 1. Assist the client to the shower and provide directions to use antibacterial soap 2. Delay the bath until the client has received antibiotic therapy for 24 hours 3. Use a bath basin with warm water and a new wash cloth for each body area 4. Use packaged pre-moistened cloths containing chlorhexidine to bathe the client

4

A nurse is making a home visit when a fire starts in the client's kitchen trash can. The client has a fire extinguisher. The nurse should take which actions to properly operate thefire extinguisher? Select all that apply. 1. Aim the nozzle at the base of the fire 2. Pull out the pin on the handle 3. Shake the canister prior to use 4. Squeeze the handle to spray 5. Sweep the spray from side to side

1,2,4,5

The home health nurse visits a client who is rehabilitating after a tibial fracture. Which interventions are appropriate to include in the client's teaching plan to promote safety in the home when using crutches? Select all that apply. 1. Keep a clear path to the bathroom 2. Look down at the feet when walking 3. Remove scatter rugs from floors 4. Use a small backpack/shoulder bag to hold personal items 5. Wear rubber-soled shoes, preferably without laces

1,3,4,5

Which of the following drug administrations should be reported as a practice error? Select all that apply. 1. Cephalexin administered; client has history of anaphylaxis from penicillin 2. Hydromorphone 2 mg administered; client reports pruritus 3. Immunization for 3-month-old administered in ventrogluteal site 4. Oral niacin (nicotinic acid) administered; client has facial flushing 5. Warfarin administered; client at 12 weeks gestation

1,3,5

All of these events are occurring at the same time. Which one should the registered nurse deal with first? 1. A health care provider (HCP) is asking to speak to the nurse 2. A visitor is seen lying on the hallway floor 3. A client is requesting an analgesic for pain rated an "8" on a 1-10 scale 4. The intravenous (IV) pump is beeping on a client who is receiving blood

2

A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the unlicensed assistive personnel (UAP). Which finding by the nurse requires intervention? 1. UAP has attached a bed alarm to the client's gown and bed 2. UAP has been making hourly rounds on the client 3. UAP has lowered the bed and raised all 4 side rails 4. UAP has placed a fall risk ID bracelet on the client's wrist

3

The nurse at the radiological imaging center is admitting a client for an MRI of the right knee. Which information obtained by the nurse should be reported immediately to the prescribing health care provider? 1. The client ate a full breakfast that morning 2. The client has an implantable cardioverter defibrillator (ICD) 3. The client is allergic to povidone-iodine 4. The client took all prescribed cardiac medications before arriving

2

The nurse admits an elderly client with a history of stroke and left-sided weakness due to change in level of consciousness, dehydration, and diarrhea secondary to recurrent clostridium difficile. What is the nurse's priority action to keep the client free of injury? 1. Place a bedside commode on the client's right side 2. Place the client in a room closest to the nursing station 3. Raise the bed rails upon leaving the room 4. Use alcohol-based hand cleaner after removing gloves

1

The charge nurse must assign a semi-private room to a client with diabetes mellitus admitted for IV antibiotic therapy to treat leg cellulitis. Which of the 4 room assignments is the best option for this client? 1. Room 1: Client 1 day postoperative laparoscopic cholecystectomy who is awaiting discharge 2. Room 2: Client with dementia and urinary incontinence wearing an external urine collection device 3. Room 3: Client with history of splenectomy 15 years ago, now admitted for pulmonary embolism 4. Room 4: Client with lupus nephritis who is prescribed treatment with azathioprine

2

When caring for an adult client who is in soft wrist restraints, what is the appropriate nursing action to prevent interference with medical treatment? 1. Assess Braden scale every 2 hours 2. Assess peripheral circulation and neurovascular status every hour 3. Offer liquids, nutrition, and toileting every 4 hours 4. Release the restraints and perform range of motion exercises (ROM) every 30 minutes

2

Which emergency department client would be allowed to leave against medical advice (AMA) after discussing the risks with the primary health care provider? 5-year-old child who needs antibiotics for meningitis and was brought in by a Christian parent Client with coffee-ground emesis from chronic use of high-dose aspirin Client who is disoriented to time and place due to urinary tract infection Client who tried to commit suicide by taking a handful of acetaminophen 1 hour ago after a fight with a significant other

2

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