ML4 CH27

A client is admitted to the hospital with tuberculosis. Which statement by the nurse explains how to reduce the risk of transmission to others?

"All visitors who enter the room must wear N95/surgical masks."

One of the leading causes of death in the United States is drowning. How can the nurse assist in lowering this statistic?

Implement drowning prevention strategies.

The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse?

Initiate use of a bed alarm.

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home?

Most people who die in house fires die of smoke inhalation rather than burns.

Which level of health care provider may make the decision to apply physical restraints to a client?

nurse practitioner

Any microorganism capable of disrupting normal physiologic body processes is a:

pathogen.

A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection?

perform hand hygiene before and after entering the client's room

An infection-control nurse is discussing needlestick injuries with a group of newly hired nurses. The infection control nurse informs the group that most needlestick injuries result from:

recapping a needle.

The nurse observes an unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene?

removes gloves and walks out of the room

Surgical asepsis is defined as:

absence of all microorganisms.

A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first?

Conceal IV tubing with gauze wrap

A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:

automobile accidents.

The parent of a pediatric client tells the nurse, "I do not believe in vaccinations." What is the appropriate nursing response?

"Help me understand your perspective about vaccinating."

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?

"Is your child breathing at this time?"

The nurse is preparing to apply prescribed extremity restraints to a client's ankles. Place in order the steps of the procedure the nurse should perform. Use all options.

1.Explain rationale for use to the client and family. 2.Pad bony prominences. Wrap the restraint around the client's ankle and secure it with hook-and-loop fastener straps. 3.Ensure that two fingers fit between the restraint and the client's skin. 4.Position limbs in normal anatomic position. 5.Secure restraints to the bed frame with quick-release knots.

The community health nurse is talking with four clients. Who does the nurse identify that would most benefit from teaching about alcohol and drug use?

19-year-old male college student majoring in physics

A client is being screened for a parasitic infection and the physician orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for:

3 days.

The nurse is providing safety teaching to the family of an older adult client. Which finding in the client's home will the nurse teach the family to address?

A hair dryer is placed next to the sink.

A school-age child is admitted to the emergency room with a possible concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client?

Assessment of vital signs and respiratory status

Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age?

Always provide close supervision for young children when they are in or around pools and bathtubs."

The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation?

Ask to examine the client alone in order to speak to her privately.

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first?

Assess the need for assistance with ambulation.

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?

Avoid unattended baths for the toddler.

A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan?

Childproofing the house

When preparing to take a client's blood pressure, the nurse notes that the sphygmomanometer is visibly soiled. What is the correct action by the nurse?

Cleanse and disinfect the sphygmomanometer.

Which item would alert the home care nurse to a safety hazard threatening a young child?

Dangling blind cords

A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply.

Drowsiness Vomiting Headache

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order?

Ensure that two fingers can be inserted between the restraint and the client's extremity.

A client has presented to the emergency department after splashing a chemical in the eyes. When managing the injury, what should be included in the plan of care?

Flush the eyes with water for 10 minutes.

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priorityrecommendation for this client?

Placing the client in a bed with a bed alarm

The nurse on a medical-surgical unit notices smoke from a client's room. Upon entering, the nurse notes that the curtain in the room is on fire. What should be the nurse's first action?

Remove the client from the room.

The friend of a long-term care client comes to visit despite having an upper respiratory infection. What health teaching will the nurse share with the visitor?

Please get a mask from the staff upon entry and use a mask along with hand hygiene when visiting to prevent the spread of infection to your friend and others.

An older adult client with an unsteady gait has been experiencing urinary urgency after being diagnosed with a urinary tract infection. What is the nurse's best action for reducing the client's risk of falls?

Provide a bedside commode and ensure adequate lighting.

What is the primary role of the nurse in the care of clients who experience domestic violence?

Providing prompt recognition of the potential or actual threat to safety

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply.

Quality improvement (QI) Client-centered care Teamwork and collaboration

The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock?

Refrain from using extension cords.

A nurse is making a home visit for a client with several home safety concerns. On which safety concept(s) would the nurse advise the client? Select all that apply.

Remove throw rugs from high traffic areas. Check the batteries in all smoke detectors. Remove extension cords from open spaces. Ensure appropriate lighting in hallways and entrances to the home.

What is an accurate guideline for the use of PPE?

Replace gloves if they are visibly soiled.

A nurse smells smoke and subsequently discovers a fire in a garbage can in a common area on the hospital unit. What is the nurse's priority action in this situation?

Rescue anyone who is in immediate danger.

A nurse finds that a fire has broken out in a client's room at the health care facility. Which intervention is of the highest priority?

Rescue the client.

A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan?

Restrain the baby in a car seat.

Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk?

Social pressure

The nurse is teaching the caregiver of a 8-month-old infant about safety. Which teaching will the nurse include?

Supervise your child on the changing table.

A client has been diagnosed with a glioblastoma and the care team has determined that this brain tumor is inoperable. Which aspects of the client's subsequent care demonstrate adherence to the Quality and Safety Education for Nurses (QSEN) competencies? Select all that apply.

The care team meets with the client and family promptly to identify their preferences for treatment. The care team balances the best available evidence about glioblastoma treatment with the client's preferences. Nurses proactively identify threats to the client's safety that may occur as treatment is provided. Each member of the care team uses the best available technology to organize and provide care.

he nurse reminds the visitor of a client with an antibiotic-resistant infection that gloves are necessary. The visitor states, "I need to directly hold my loved one's hand without a barrier." What essential information does the nurse need to explain to the visitor to prevent transmission of the organism?

The glove is an important barrier in preventing the transmission of your loved-one's antibiotic-resistant infection to you or other people you come in contact with.

The home care nurse observes that a child is learning to ride a bicycle. Which would the nurse teach the child about bicycle safety?

The importance of wearing a helmet

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?

The nurse should question the client about the source of the bruises.

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report?

The nurse should record the incident in the client's medical record and fill out a safety event report separately.

A nurse was injured when a client with Alzheimer disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate?

The report provides a detailed and objective account of the circumstances before, during, and after the event

Infection occurs when the host is exposed to pathogens. What type of pathogen uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup?

Virus

Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for a 9-month-old infant?

We place our baby in a rear-facing car seat in the back seat of the car."

The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based hand rub is appropriate in which situation?

When hands are visibly soiled

In which situation is an alcohol-based rub not the appropriate option for hand hygiene?

When the nurse's hands are visibly soiled

A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint?

a dose of an antipsychotic

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate?

administration of an antipsychotic agent to alter the client's behavior

Which client would require a negative flow room?

an 81-year-old man with active tuberculosis and a productive cough

The nurse is caring for a 27-year-old client who presents with possible signs of an infected abdominal wound. Which action should the nurse prioritize and initiate after receiving the results of the laboratory test indicating the client has methicillin-resistant Staphylococcus aureus(MRSA) infection?

contact

A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should:

fill out an incident report, with the goal of preventing a similar event in the future

Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile?

gown and gloves

When educating families on fire safety, it is important to:

have a meeting place outside the home.

A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized?

identifying systemic factors on the unit that may have contributed to the event

he nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail to prevent this behavior, and chemical restraints fail, which treatment does the nurse anticipate will be ordered?

temporary application of devices that reduce the client's ability to move arms

The nurse is working at a local elementary school. A mother arrives to pick up her 6-year-old son and has her 2-year-old daughter in tow. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse?

the 2-year-old leaning against the screen of a window in a classroom

Which is not appropriate regarding the use of gowns as PPE?

use of one gown per person per shift

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)?

wearing a particulate respirator for all care and interaction with this client