NCLEX Chapter 6

A nurse is assisting in the emergency room of a small local hospital when a client with multiple gunshot wounds arrives by ambulance. The nurse is asked to care for the client's personal belongings, which may be needed as legal evidence. Which of the following actions by the nurse is contraindicated in the proper handling of legal evidence? 1. Giving the clothing and wallet to the family 2. Cutting clothing along seams, avoiding bullet holes 3. Placing personal belongings in a labeled sealed paper bag 4. Initiating a log (custody log) that provides tracking and handling items needed for evidence

1. Giving the clothing and wallet to the family Rationale: Basic rules for handling evidence include limiting the number of people with access to the evidence, initiating a chain of custody log to track handling and movement of evidence, and carefully removing clothing to avoid destroying evidence. This usually includes cutting clothes along seams, avoiding areas where there are obvious holes or tears. Potential evidence is never released to the family to take home.

A nurse is preparing to assist a client from the bed to chair using a hydraulic lift. The nurse should do which of the following to move the client safely with this device? 1. Position the client in the center of the sling 2. Have three staff members available to assist 3. Lower the client rapidly once positioned over the chair 4. Have the client grasp the chains attaching the cling to the lift

1. Position the client in the center of the sling Rationale: One person may operate a hydraulic lift. The client is positioned in the center of the sling, which is then attached to chains or straps that connect the sling to the lift. The client is raised from the bed into a sitting position. The lift raises the client off the mattress and lowers the client slowly once the sling is positioned over the chair.

A clinic nurse is providing instructions to a mother of a child who was diagnosed with mumps. The mother is concerned about her other children and asks the nurse how the infection is transmitted. The nurse informs the mother that mumps is transmitted by: 1. Fecal oral route 2. Airborne droplets 3. Contact with tears 4. Contact with body sweat

2. Airborne droplets Rationale: Mumps id transmitted via airborne droplets, salivary secretions, and possibly the urine. Options 1, 3 and 4 are incorrect.

A client who received a dose of chemotherapy 12 hours ago is incontinent of urine while in bed. The nurse safely wears which of the following when cleaning the client? 1. Mask and gloves 2. Gown and gloves 3. Mask, gown and gloves 4. Gown, gloves and eyewear

2. Gown and gloves Rationale: The client who has received chemotherapy will have antineoplastic agents or their metabolites in body fluids and excreta for 48 hours. For this reason, the nurse should wear protection for likely sources of contamination. In this instance, the nurse should wear gloves and a gown to protect the hands and uniform from contamination.

A nurse is caring for a client who is dying and is a potential organ donor. The nurse reviews the client's medical record and identifies a contraindication to organ donation if which of the following were documented in the client's record? 1. Age of 38 years 2. Hepatitis B infection 3. Allergy to penicillin type antibiotics 4. Negative rapid plasma reagin (RPR) laboratory result

2. Hepatitis B infection Rationale: A potential organ donor must meet age eligibility requirements, which vary by organ. For example, age must not exceed 65 (kidney donation), 55 (pancreas and liver), or 40 (heart) years old. The client should be free of communicable disease such as human immunodeficiency virus or hepatitis, and the involved organ may not be diseased. Another contraindication to transplant is malignancy, with the exception of noninvolved skin and cornea.

A nurse is preparing to transfer an average-sized client with right-sided hemiplegia from the bed to the wheelchair. The client is able to support weight on the unaffected side and the nurse plans to use the hemiplegic transfer technique. The client is sitting upright in bed with the legs dangling over the side. For the safest transfer, where should the wheelchair be positioned? 1. Next to either leg 2. Near the client's left leg 3. Near the client's right leg 4. As space in the room permits

2. Near the client's left leg Rationale: Although space in the room is an important consideration for placement of the wheelchair for a transfer, when the client has an affected lower extremity, movement should always occur toward the client's unaffected (strong) side. For example, if the client's right leg is affected and the client is sitting on the edge of the bed, the wheelchair is positioned next to the client's left side. This wheelchair position allows the client to use the unaffected leg effectively and safely.

A nurse is assisting in preparing a client scheduled for a bone marrow aspiration. The client asks the nurse if the procedure will be painful. To provide the client with accurate information, the nurse should incorporate which of the following in a response to the client? 1. There is no pain from the procedure at all 2. The procedure is painful, but the client will be under anesthesia 3. A local anesthetic is used, but there is some pain during aspiration 4. The procedure is very painful, but the client will be heavily medicated beforehand

3. A local anesthetic is used, but there is some pain during aspiration Rationale: A local anesthetic is used to anesthetize the skin and subcutaneous tissue to minimize tissue discomfort with needle insertion. The client will feel some pain briefly when the sample is aspirated out of the marrow. Options 1, 2 and 4 are not true statements.

An older client in a long-term care facility is at risk for injury because of confusion. Because the client's gait is stable, which method of restraint, if prescribed, would be best used by the nurse to prevent injury to the client? 1. Vest restraint 2. Waist restraint 3. Alarm-activating bracelet 4. Chair with a locking lap-tray

3. Alarm-activating bracelet Rationale: If the client is confused and has a stable gait, the least intrusive method of restraint is the use of an alarm-activating bracelet, or "wandering bracelet." This allows the client to move about the residence freely while preventing him or her from leaving the premises. A vest or waist restraint or a chair with a locking lap tray is more intrusive than an alarm-activating bracelet.

A nurse working on a medical nursing unit during an external disaster is called to assist with the care of clients coming into the emergency room and is asked to assist the triage nurse. Using principles of prioritizing, the nurse initiates care for a client with which of the following injuries first? 1. Fractured tibia 2. Penetrating abdominal injury 3. Bright red bleeding from a neck wound 4. Open severe head injury in a deep coma

3. Bright red bleeding from a neck wound Rationale: The client with arterial bleeding from a neck wound is in immediate need of treatment to save the client's life. According to the triage process, the client in this classification would be issued a red tag. The client with the penetrating abdominal injury would be tagged yellow and classified as "delayed," requiring intervention within 30 to 60 minutes. A green or "minimal" designation would be given to the client with a fractured tibia; this client requires intervention but can provide self care if needed. A designation of "expectant" and color code "black" would be applied to the client with massive injuries and a minimal chance of survival. These clients are given definitive treatment last.

The pregnant client is at full term. The fetal heart rate (FHR) is being monitored for a baseline rate. The nurse is satisfied with the results and tells the client that the baby is safe and that the baby's heart rate is within normal limits. The nurse bases this interpretation on which of the following data? 1. FHR of 80 beats per minute 2. FHR of 90 beats per minute 3. FHR of 140 beats per minute 4. FHR of 170 beats per minute

3. FHR of 140 beats per minute Rationale: The average FHR is 140 beats per minute. The normal range is 110 to 160 beats per minute; therefore option 3 is the only correct option.

A client who suffered a severe head injury has had vigorous treatment to control cerebral edema. Brain death has now been determined. The nurse assigned to assist in caring for the client prepares to carry out which of the following orders that will maintain viability of the kidneys before organ donation? 1. Checking respirations 2. Monitoring temperature 3. Frequent range of motion to extremities 4. Administration of intravenous (IV) fluids

4. Administration of intravenous (IV) fluids Rationale: Perfusion to the kidney is affected by blood pressure, which is in turn affected by blood vessel tone and fluid volume. Therefore the client who was previously dehydrated to control intracranial pressure is now in need of rehydration to maintain perfusion to the kidneys. The nurse prepares to infuse IV fluids as ordered and to continue monitoring urine output. Checking respirations and temperature and frequent range of motion to extremities will not maintain viability of the kidneys.

A nurse is orienting a nursing assistant to the clinical nursing unit. The nurse should intervene if the nursing assistant did which of the following during a routine hand washing procedure? 1. Kept the hands lower than the elbows 2. Washed continuously for 10 to 15 seconds 3. Use 2 to 5 mL of soap from the dispenser 4. Dried the hands from the forearm down to the fingers

4. Dried the hands from the forearm down to the fingers Rationale: Proper hand washing procedure involves wetting the hands and wrists and keeping the hands lower than the forearms so water flows toward the fingertips. The nurse uses 3 to 5 mL of soap and scrubs for 10 to 15 seconds using a rubbing and circular motion. The hands are rinsed and then dried, moving from the fingers to the forearms. The paper towel is then discarded, and a second one is used to turn off the faucet to avoid hand contamination.

A nurse is assigned to care for a client with cervical cancer who has an internal radiation implant. Which of the following required items should the nurse ensure is kept in the client's room during this treatment? 1. A lead shield 2. A bedside commode 3. A no. 16 Foley catheter 4. Long-handled forceps and a lead container

4. Long-handled forceps and a lead container Rationale: In the case of dislodgement of an internal radiation implant, the radioactive source is never touched with the bare hands. It is retrieved with long-handled forceps and placed in the lead container kept in the client's room. In many situations the client has a Foley catheter inserted and is on bed rest during treatment to prevent dislodgement. Although a lead shield may be in the room, it is not the required item. Nurses wear a dosimeter badge while in the client's room to measure the exposure to radiation.

A nurse is delivering a meal tray to a client with heart failure. The nurse should remove which item from the tray before bringing it to the client's bedside because the food item would be unsafe for the client to consume? 1. Sherbet 2. Green beans 3. Baked chicken 4. Saltine crackers

4. Saltine crackers Rationale: Clients with heart failure should monitor and restrict sodium intake. Saltine crackers are high in sodium and should be avoided. Green beans and sherbet are low in sodium. Baked chicken would contain only physiological saline because it is an animal product and would not have to be avoided by the client.

A client has a tracheostomy with a nondisposable inner cannula. After completing tracheostomy care, the nurse reinserts the inner cannula into the tracheostomy tube immediately after doing which of the following? 1. Suctioning the airway 2. Rinsing it in sterile water 3. Drying it with a sterile cotton ball 4. Tapping it dry lightly against a sterile surface

4. Tapping it dry lightly against a sterile surface Rationale: The nurse reinserts the inner cannula immediately after tapping it dry against a sterile surface. Once inserted, it is turned clockwise to lock it into place. It should not be dried with a cotton ball, which could leave cotton particles on the cannula. The client's airway is suctioned before doing tracheostomy care. It is rinsed in sterile water before it is tapped.

A nurse is assisting in the care of a client with a nasogastric (NG) tube. The nurse understands that which of the following would be the most potentially hazardous method for checking tube placement when giving care to the client? 1. Measuring the pH of gastric aspirate 2. Submerging the NG tube in water to check for bubbling 3. Aspirating the NG tube with a 50 mL syringe for gastric contents 4. Instilling 10 to 20 mL of air into the NG tube while auscultating over the stomach

2. Submerging the NG tube in water to check for bubbling Rationale: The most potentially hazardous method for checking NG tube placement is to submerge the end of the tube in water to observe for bubbling. This could put the client at risk for aspiration if the client breathed in fluid while the tube was in the lungs. Each of the other methods described is acceptable. The best method of determining tube placement is to verify by x-ray.

A physician prescribes 1000 mL of normal saline to be infused over 12 hours. The drop factor is 15 drops per milliliter. To administer the infusion safely, the nurse adjusts the flow rate at how many drops? 1. 15 drops 2. 18 drops 3. 21 drops 4. 28 drops

3. 21 drops Rationale: Use the formula for calculating intravenous (IV) drop rates. Formula: Total volume in mL X drop factor/Time in minutes = Flow rate in drops per minute 1000 mL X 15 drops/720 minutes = 15000/720 = 20.8 or drops 21 drops per minute

A nurse is asked to check the corneal reflex on an unconscious client. The nurse should use which of the following as the safest stimulus to touch the client's cornea? 1. Sterile glove 2. Wisp of cotton 3. Sterile drop of saline 4. Tip of a 1 mL syringe

3. Sterile drop of saline Rationale: The client who is unconscious is at risk of corneal abrasion. The safest way to test the corneal reflex is by using a drop of sterile saline. Options 1, 2 and 4 can cause injury to the cornea.

A nurse is observing a nursing assistant talking to a client who is hearing impaired. The nurse should intervene if which of the following were performed by the nursing assistant during communication with the client? 1. The nursing assistant is speaking in a normal tone 2. The nursing assistant is speaking clearly to the client 3. The nursing assistant is facing the client when speaking 4. The nursing assistant is speaking directly into the impaired ear

4. The nursing assistant is speaking directly into the impaired ear. Rationale: When communicating with a hearing impaired client, the nurse should speak in a normal tone to the client and should not shout. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express the statement differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear.

Ultraviolet light (UVL) therapy is prescribed in the treatment plan for a client with psoriasis. The nurse reinforces instructions to the client regarding safety measures related to the therapy. Which statement made by the client indicates a need for further instructions? 1. "Each treatment will last 30 minutes." 2. "I will expose only the area requiring treatment." 3. "I should wear eye goggles during the treatment." 4. "I will cover my face with a loosely applied covering."

1. "Each treatment will last 30 minutes." Rationale: Safety precautions are required during UVL therapy. Most UVL treatments require the person to stand in a light treatment chamber for up to 15 minutes. It is best to expose only those areas requiring treatment to the UVL. Placing protective wrap-around goggles prevents exposure of the eyes to the UVL. The face should shielded with a loosely applied cloth if it is unaffected. Direct contact with the light bulbs of the treatment unit should be avoided to prevent burning of the skin.

A nurse who begins to administer medications to a client via a nasogastric feeding tube suspects that the tube has become clogged. The nurse should take which safe action first? 1. Aspirate the tube 2. Flush the tube with warm water 3. Prepare to remove and replace the tube 4. Flush with a carbonated liquid such as cola

1. Aspirate the tube Rationale: the nurse should first attempt to unclog the feeding tube by aspirating it. If this does not work, the nurse should try to flush the tube with warm water. Carbonated liquids such as cola may also be used, but only if agency policy identifies it as acceptable. Replacement of the tube is the last step if others are unsuccessful.

A client with paraplegia has a risk for injury related to spasticity of leg muscles. The nurse avoids which action that would be least helpful in dealing with this problem? 1. Using restraints to immobilize the limbs 2. Administering a PRN order for a muscle relaxant 3. Removing potentially harmful objects placed near the client 4. Performing range-of-motion exercises with the affected limb

1. Using restraints to immobilize the limbs Rationale: Using limb restraints will not alleviate spasticity and could harm the client. Their use should be avoided. Use of muscle relaxants may be helpful if the spasms cause discomfort to the client or pose a risk to the client's safety. Removing potentially harmful objects is a good basic safety measure. Range-of-motion exercises are beneficial in stretching muscles, which may diminish spasticity.

A nurse is caring for a child with a fever. The nurse implements which safe action when giving this child a tepid tub bath? 1. Add some alcohol to the bath water 2. Let the child soak in the tub for 10 minutes 3. Add cool water slowly to the warmer bath water 4. Warm the water to the same body temperature of the child

3. Add cool water slowly to the warmer bath water Rationale: Cool water should be added to an already warm bath because this will cause the water temperature to slowly drop. The child will be able to gradually adjust to the changing water temperature and will not experience chilling. The child should be in a tepid tub bath for 20 - 30 minutes to achieve maximum results. To achieve the best cooling results for the child with a fever, the water temperature should be at least 2 degrees lower than the child's body temperature.

A nurse who is assisting in the care of a client with cardiomyopathy should give priority to which of the following to ensure client safety> 1. Administering vasodilator medications 2. Conducting a thorough pain assessment 3. Taking measures to prevent orthostatic changes when the client stands 4. Telling the client about the importance of avoiding over-the-counter medications

3. Taking measures to prevent orthostatic changes when the client stands Rationale: Orthostatic changes can occur in the client with cardiomyopathy as a result of impaired venous return. These changes could lead to dizziness and client falls. Vasodilators should not be administered. There is no mention of pain in the question, and pain may not directly affect safety in this event. Option 4 is an accurate statement but is not directly related to the subject of the question.

A licensed practical nurse witnesses an accident in which a victim was hit by a car. The nurse stops at the scene of the accident and administers safe care to the victim, who sustained a compound fracture of the femur. The victim is hospitalized and later develops sepsis as a result of the fractured femur. The victim files a suit against the nurse who provided care at the scene of the accident. Which of the following most accurately describes the nurse's immunity from this suit? 1. The Good Samaritan Law will not protect the nurse 2. The Good Samaritan Law protects lay persons and not professional health care providers 3. The Good Samaritan Law will protect the nurse if the care given at the scene is not negligent 4. The Good Samaritan Law always provides immunity from the suit even if the nurse accepted compensation for the care provided

3. The Good Samaritan Law will protect the nurse if the care given at the scene is not negligent Rationale: A Good Samaritan law is passed by the state legislature to encourage nurses and other health care providers to provide care to a person when an accident, emergency or injury occurs, without fear of being sued for the care provided. Called immunity from suit, this protection usually applies only if all of the conditions of the law are met, such as the health care provider receives no compensation for the care provided, and the care given is not willfully and wantonly negligent.

A client with pulmonary tuberculosis (TB) asks the nurse how this disease was contracted. The nurse replies that TB is commonly spread by which of the following methods? 1. Sneezing 2. Shaking hands 3. Contact with stool 4. Contact with urine

1. Sneezing Rationale: TB is spread by droplet nuclei, which become airborne when the infected client laughs, sings, sneezes, or coughs. An individual must inhale the droplet nuclei for the chain of infection to continue. Therefore it is not spread by shaking hands or contact with stool or urine.

A client is scheduled for a bone marrow aspiration. The nurse plans to bring which of the following skin cleansing agents to the bedside before this procedure for skin cleansing to prevent infection as a result of the procedure? 1. Alcohol swabs 2. Soap and water 3. Povidone-iodine 4. Hydrogen peroxide

3. Povidone-iodine Rationale: Before bone marrow aspiration, the needle insertion site is cleansed with an antiseptic solution such as povidone-iodine. This helps reduce the number of bacteria on the skin and decreases the risk of infection from the procedure. The other options are incorrect agents because they would not produce this effect.

A client is scheduled to have insertion of an inferior vena cava (IVC) filter. The nurse should place highest priority on determining whether the surgeon wants which of the following medications held in the preoperative period? 1. Furosemide (Lasix) 2. Famotidine (Pepcid) 3. Multivitamin with minerals 4. Warfarin sodium (Coumadin)

4. Warfarin (Coumadin) Rationale: The nurse is careful to question the surgeon about whether warfarin sodium should be administered in the preoperative period before insertion of an IVC filter. This medication is often withheld during the preoperative period to minimize the risk of hemorrhage during surgery. The other medications may also be withheld if specifically ordered, but usually they are discontinued as part of an NPO (nothing by mouth) after midnight order.

A client is admitted to the hospital with severe hypoparathyroidism. The nurse should do which of the following activities to promote client safety? 1. Keep the room slightly cool 2. Institute seizure precautions 3. Keep the head of bed lowered 4. Use a waist restraint continuously

2. Institute seizure precautions Rationale: Hypoparathyroidism results from insufficient parathyroid hormone, leading to low serum calcium levels. Hypocalcemia can cause tetany, which, if untreated can lead to seizures. The nurse should institute seizure precautions to maintain a safe environment. The other options do nothing to help this health problem or promote a safe environment for this client.

A client has cognitive-perceptual difficulties and problems with fine motor coordination. The nurse working with this client should read the progress notes from which of the following health team members to obtain suggestions for working with him or her? 1. Social worker 2. Speech pathologist 3. Recreational therapist 4. Occupational therapist

4. Occupational therapist Rationale: The occupational therapist focuses on the development or relearning of fine motor skills. Social workers, speech pathologists and recreational therapists do not address these types of client problems.

A nurse is planning to give a subcutaneous injection of insulin. The nurse plans to do which of the following immediately after giving the injection? 1. Break the needle 2. Recap the needle 3. Place the needle and syringe in a labeled cardboard box 4. Place the needle and syringe in a labeled, rigid plastic container

4. Place the needle and syringe in a labeled, rigid plastic container Rationale: Standard precautions include specific guidelines for handling of sharps. Needles should not be recapped, bent, broken, or cut after use. They should be disposed of in a labeled, impermeable container that is specifically used for this purpose. Needles should not be discarded in cardboard boxes because they could puncture the cardboard, causing needlestick injury. Needles should always be properly discarded after use.

A client who is immunosuppressed is being admitted to the hospital on neutropenic precautions. The nurse assigned to care for the client plans to ensure that which of the following does not occur in the care of the client? 1. Admitting the client to a semiprivate room 2. Placing a mask on the client if the client leaves the room 3. Removing a vase with fresh flowers left by a previous client 4. Placing a "See the Nurse before Entering" sign on the door to the room

1. Admitting the client to a semiprivate room Rationale: The client who is on neutropenic precautions is immunosuppressed and therefore is admitted to a single room on the nursing unit. A sign indicating "See the Nurse before Entering" should be placed on the door to the client's room so that the nurse can ensure that neutropenic precautions are implemented by anyone entering the room. Sources of standing water and fresh flowers should be removed to decrease the microorganism count. The client should wear a mask for protection from exposure to microorganisms whenever he or she leaves the room.

A nurse is preparing to suction a client's tracheostomy. To ideally promote deep breathing and coughing, in which position should the client be safely placed? 1. Supine 2. Lateral position 3. High-Fowler's position 4. Semi-Fowler's position

4. Semi-Fowler's position Rationale: If it is not contraindicated, before suctioning a tracheostomy, the client is placed in semi-Fowler's position to promote deep breathing, maximum lung expansion, and productive coughing. With the client in this position, gravity pulls downward on the diaghram, which allows greater chest expansion and lung volume. Options 1 and 2 would not provide maximum lung expansion. The high-Fowler's position would not allow for easy visualization of the tracheostomy or easy access of the suction catheter.

A nurse who is assisting in the care of suicidal clients in a psychiatric nursing unit should plan to implement special precautions at which of the following times of increased risk? 1. Day shift 2. Weekdays 3. Shift change 4. 8 am to 2 pm

3. Shift change Rationale: During the change of shifts, fewer staff members may be available to observe clients. The staff in a psychiatric nursing unit should increase precautions during shift change for clients identified as suicidal. Other times of increased risk for suicides are weekends (not weekdays), and the night shift (not day shift).

A registered nurse (RN) tells a licensed practical nurse (LPN) that a client who is suspected of having tuberculosis (TB) is being admitted to the hospital and asks the LPN to prepare a room for the client. The LPN prepares the room, knowing that this client's room needs to provide which of the following? 1. Venting to the roof and ultraviolet light 2. Ultraviolet light and three room air exchanges per hour 3. Ten room air exchanges per hour and venting to the roof 4. Venting to the outside, six room air exchanges per hour, and ultraviolet light

4. Venting to the outside, six room air exchanges per hour, and ultraviolet light Rationale: The client with tuberculosis must be admitted to a private room that provides at least six air exchanges per hour. The room should provide venting to the outside and have ultraviolet lights installed. Options 1, 2 and 3 are inaccurate and would not provide adequate protection to help prevent transmission of the infection.

A client tells the nurse that she has seen many articles in the health care section of the newspaper about case management and asks the nurse what this means. To provide the client with accurate information, the nurse tells the client which of the following? 1. "It represents an interdisciplinary health care delivery system." 2. "One nurse takes care of one client and is responsible for that client." 3. "One nurse supervises all of the other employees when they care for clients." 4. "A single case manager plans the care for all of the clients in the nursing unit."

1. "It represents an interdisciplinary health care delivery system." Rationale: Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources to maximize hospital revenues while providing for optimal outcome of care. Case management manages client care by managing the client care environment. Options 2, 3 and 4 are incorrect descriptions.

A client is prepared to receive elective cardioversion to treat atrial fibrillation. Which of the following is an unsafe preprocedure observation? 1. The client's digoxin has been withheld for the last 48 hours. 2. The synchronizer on the defibrillator is turned on and set at 50 joules. 3. The client has received an intravenous (IV) dose of midazolam (Versed). 4. The client is wearing a nasal cannula delivering oxygen at 2 liters per minute.

4. The client is wearing a nasal cannula delivering oxygen at 2 liters per minute. Rationale: Digoxin may be withheld for up to 48 hours before cardioversion because it increases ventricular irritability and may cause ventricular dysrhythmias after countershock. The client typically receives an IV dose of a sedative or antianxiety agent. The defibrillator is switched synchronizer mode to time the delivery of the electrical impulse to coincide with the QRS complex and avoid the T wave, which should cause ventricular fibrillation. Energy level is typically set at 50 to 100 joules. During the procedure any oxygen is removed temporarily because oxygen supports combustion, and a fire could result from electrical arcing.

A postpartum client has been diagnosed with endometritis. The nurse who is reinforcing teaching about how to prevent the spread of infection to the newborn should tell the mother to: 1. Keep the newborn in the Isolette 2. Ask visitors not to hold the newborn 3. Wear a mask to prevent spread of airborne droplets 4. Wash hands carefully before picking up the newborn

4. Wash hands carefully before picking up the newborn Rationale: Infectious diseases can be transmitted through contaminated items such as hands and bed liners in clients with endometritis. Hand washing is one of the most effective methods to prevent transmission of this infectious disease because it breaks the chain of infection. Options 2 and 3 are not related to the route of transmission of this infection. Option 1 is unnecessary.

A nurse who is assisting in the care of a client with cancer is following medication orders to manage the cancer pain. Which of the following strategies should the nurse follow to ensure adequate and safe pain control? 1. Try multiple simultaneous medications for maximum pain relief effect 2. Rely entirely on prescription and over-the-counter medications for pain relief 3. Ensure that the client is kept at a low baseline pain level to avoid sedation or addiction 4. Start with low medication doses and gradually increase to a dose that relieves pain without exceeding the maximal daily dose

4. Start with low medication doses and gradually increase to a dose that relieves pain without exceeding the maximal daily dose Rationale: The most appropriate approach is to begin with low doses and increase as needed to maintain a dose that relieves the pain. Option 2 ignores the benefits of other options that may relieve pain such as massage, therapeutic touch, or music. Keeping the client at a baseline level is inappropriate practice. Multiple medication interventions do not guarantee effectiveness and can also be unsafe.

A nurse is giving a bed bath to a client who is on strict bed rest. To safely increase venous return, the nurse bathes the client's extremities by using: 1. Long, firm strokes from distal to proximal areas 2. Short, patting strokes from distal to proximal areas 3. Firm, circular strokes from proximal to distal areas 4. Smooth, light strokes back and forth from proximal to distal areas

1. Long, firm strokes in the direction of venous flow promote venous return when the extremities are bathed. Circular strokes are used on the face. Short, patting strokes and light strokes are not as comfortable for the client and do not promote venous return.

A client with thrombophlebitis is being treated with heparin sodium (Liquaemin) therapy. The registered nurse (RN) asks the licensed practical nurse (LPN) to check the medication supply to ensure that the antidote for this therapy is available. The nurse checks the medication supply for which medication? 1. Protamine sulfate 2. Streptokinase (Streptase) 3. Phytonadione (vitamin K) 4. Aminocaproic acid (Amicar)

1. Protamine sulfate Rationale: Protamine sulfate is the antidote for heparin sodium. Streptokinase is a thrombolytic agent used to dissolve blood clots. Vitamin K is the antidote for warfarin (Coumadin). Amicar is an antifibrinolytic used to prevent the breakdown of clots already formed.

A nurse is assigned to care for an older client who has been identified as a victim of physical abuse. In planning care for this client, the nurse's priority is focused toward: 1. Removing the client from any immediate danger 2. Adhering to the mandatory abuse reporting laws 3. Encouraging the client to file charges against the abuser 4. Referring the abusing family member for treatment

1. Removing the client from any immediate danger Rationale: Whenever the abused client remains in the abusive environment, priority must be placed on determining whether the person is in any immediate danger. If so, emergency action must be taken to remove him or her from the abusing event. Options 2 and 4 may be appropriate but are not the priority. Option 3 is not an appropriate intervention at this time and may produce increased fear and anxiety in the client.

A licensed practical nurse (LPN) is asked to prepare a room for a child who will be admitted to the pediatric unit with a diagnosis of tonic-colonic seizures. The LPN prepares the room and plans to place which of the following items at the bedside? 1. Suction apparatus and oxygen 2. A tracheotomy set and oxygen 3. An endotracheal tube and an airway 4. An emergency cart and padded side rails

1. Suction apparatus and oxygen Rationale: Tonic-clonic seizures cause tightening of all body muscles followed by tremors. An obstructed airway and increased oral secretions are the major complications during and after a seizure. Suction apparatus, oxygen and an airway are helpful to prevent choking and cyanosis. Options 2, 3 and 4 are incorrect. Inserting a tracheostomy or endotracheal tube is not done. It is not necessary to have an emergency cart at the bedside, but a cart should be available in the treatment room or in the nursing unit.

A nurse is implementing measures to prevent the spread of infection to other clients. The nurse understands that which of the following is the best way to prevent the spread of infection? 1. Use proper hand washing techniques 2. Use sterile technique with all procedures 3. Never stop in the middle of performing a procedure 4. Read the policy and procedure manual before performing treatments

1. Use proper hand washing techniques Rationale: Proper hand washing is the best way to prevent the spread of infection. All procedures do not require sterile technique. Reading the policy and procedure manual does not guarantee that infection will not be spread. It may be necessary in some events to stop in the middle of performing a procedure, but option 3 is not the best way to prevent the spread of infection.

A nurse employed in a long-term care facility is preparing to administer medications to an assigned client and notes that order for furosemide (Lasix) is higher than the recommended dosage. The nurse calls the physician to clarify the order and asks the physician to prescribe a dosage within the recommended range. The physician refuses to change the order and instructs the nurse to administer the dose as prescribed. Which of the following actions should the nurse take? 1. Discontinue the order 2. Contact the nursing supervisor 3. Administer the dose as prescribed 4. Call the state medical board and report the physician

2. Contact the nursing supervisor Rationale: If the physician writes an order that requires clarification, it is the nurse's responsibility to contact the physician for clarification. If there is no resolution regarding the order because the order remains as it was written after talking with the physician or because the physician cannot be located, the nurse should then contact the nurse manager or supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the order until clarification is obtained. Option 1 is not within the scope of nursing practice. Option 4 is a premature action.

A licensed practical nurse (LPN) who is assisting a registered nurse (RN) in caring for a client in active labor should do which of the following to best prevent fetal heart rate decelerations? 1. Begin preparations for a cesarean delivery 2. Encourage upright or side-lying maternal position 3. Measure maternal and fetal vital signs every 30 minutes 4. Suggest asking the physician about the advisability of an oxytocin (Pitocin) drip

2. Encourage upright or side-lying maternal position Rationale: Side-lying and upright positions such as walking, standing and squatting can improve venous return and encourage effective uterine activity, which in turn will reduce the likelihood of fetal heart rate decelerations. Cesarean delivery will not prevent decelerations. Measuring vital signs every 30 minutes will do nothing to prevent decelerations. Oxytocin could aggravate fetal heart rate decelerations because of increased uterine activity and decreased uteroplacental perfusion.

A licensed practical nurse (LPN) is assisting a registered nurse (RN) in caring for a client who just underwent cardiac catheterization using the femoral artery approach. The nurse should avoid taking which of the following actions in caring for this client because it is unsafe? 1. Resume prescribed medications 2. Have the client sit upright for a meal 3. Encourage the client to drink extra fluids 4. Ask the client to wiggle the toes when collecting data about neurovascular status

2. Have the client sit upright for a meal Rationale: For 6 hours after cardiac catheterization using the femoral approach (or per physician's orders), the client should not bend or hyperextend the affected leg to avoid blood vessel occlusion or hemorrhage. This means that having the client sit upright would be contraindicated. The precatheterization medications are generally resumed after the procedure. Asking the client to wiggle the toes to determine neurovascular status is acceptable and should be done because vascular status could be impaired if a hematoma or thrombus were developing. Fluids should be increased to aid in eliminating the contrast medium through the kidneys.

A nurse arrives to work on the day shift and is assigned to care for a client with terminal cancer. The nurse notes that the client has been receiving a narcotic analgesic every 3 hours for pain. When entering the client's room, the client states, "I am so glad you are here. The medicine never works when the nurse who cared for me last night gives it to me." The nurse has previously observed the same occurrence with this client and other clients and suspects that the night nurse is substance impaired. Which of the following actions should the nurse take? 1. Report the information to the police 2. Report the information to a supervisor 3. Call the impaired nurse organization and report the nurse 4. Call the night nurse who gave the medication and discuss the event with the nurse.

2. Report the information to a supervisor Rationale: The Nurse Practice Act requires reporting the suspicion of impaired nurses. The Board of Nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. The suspicion should be reported to the nursing supervisor who will then report to the Board of Nursing. Option 4 is incorrect and may cause a conflict. Option 1 and 3 are premature actions.

A nurse reinforces information about the disease and recuperation to the client diagnosed with tuberculosis. The nurse determines that the client understands the information presented if the client states that it is possible to return to work when: 1. Five sputum cultures are negative 2. Three sputum cultures are negative 3. The PPD and chest x-ray are negative 4. A sputum culture and a PPD test are negative

2. Three sputum cultures are negative Rationale: The client must have sputum cultures performed every 2 to 4 weeks after antituberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative because the client is considered noninfectious at that point. One negative sputum culture is not sufficient, and five negative cultures are unnecessary.

Sertraline (Zoloft) is prescribed to treat depression. The nurse reviews the client's record and consults the physician if which of the following is noted? 1. A history of diabetes mellitus 2. Use of phenelzine sulfate (Nardil) 3. A history of myocardial infarction 4. A history of irritable bowel syndrome

2. Use of phenelzine sulfate (Nardil) Rationale: Sertraline (Zoloft) is a serotonin reuptake inhibitor and antidepressant medication. Potentially fatal reactions may occur if sertraline is administered concurrently with a monoamine oxidase inhibitor (MAOI) such as phenelzine sulfate, MAOIs should be stopped at least 14 days before sertraline therapy. Conversely, sertraline should be at least 14 days before MAOI therapy. Options 1, 3, and 4 are not concerns of use of this medication.

A nurse is assisting in the care of a client in labor who has a history of sickle cell anemia. Knowing that the client has a high risk for sickling crisis during labor, the nurse should give priority to implementing which safe nursing action to prevent a crisis from occurring? 1. Maintain strict hand washing technique 2. Give the client reassurance and encouragement 3. Ensure that the client uses oxygen during labor 4. Remind the client not to bear down for more than 3 seconds

3. Ensure that the client uses oxygen during labor Rationale: Administering oxygen as needed is an effective intervention to prevent sickle cell crisis during labor. During the labor process the client is at high risk for being unable to meet the oxygen demands of labor and unable to prevent sickling. Option 1 is a safe nursing action, but it does nothing to prevent sickling crisis. Option 4 is not realistic and would not prevent sickling crisis. Option 2 is another generally helpful nursing measure but again is not related to prevention of sickling crisis.

A licensed practical nurse (LPN) is preparing to suction a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). The LPN should gather which of the following supplies to perform this procedure safely? 1. Gloves, gown and mask 2. Gown, mask, and protective eyewear 3. Gloves, mask, and protective eyewear 4. Gloves, gown, and protective eyewear

3. Gloves, mask, and protective eyewear Rationale: Standard precautions include the use of gloves whenever there is actual or potential contact with blood or body fluids. During suctioning the nurse wears gloves, a mask, and protective eyewear or a face shield. Impervious gowns are worn in those instances when it is anticipated that there will be contact with a large amount of body fluid or blood.

A client with Bell's palsy is scheduled for a magnetic resonance imaging (MRI). The nurse should implement which of the following standard orders to ensure a safe environment in preparation for this test? 1. Shave the groin area for insertion of a femoral catheter 2. Apply metal-tipped electrodes on the client's chest 3. Remove all objects containing metal from the client 4. Ensure that the client stays NPO for 24 hours before the test

3. Remove all objects containing metal from the client Rationale: An MRI uses magnetic fields to produce a diagnostic image. All metal objects such as rings, bracelets, hairpins and watches should be removed. The client's history should also be reviewed to determine if the client has any internal metallic devices such as orthopedic hardware, pacemakers and shrapnel. A femoral catheter is not inserted. For an abdominal MRI, the client is usually NPO, but this is not necessary for an MRI of the head. In addition, an NPO status for 24 hours is unnecessary and may be harmful to the client. Metal-tipped electrodes are not used for this test.

A client with metastatic bladder cancer is admitted to the hospital for chemotherapy. During data collection, the client tells the nurse that a living will was prepared 2 years ago and asks if the will needs to be updated. The most appropriate nursing response is which of the following? 1. "Living wills are valid for 6 months." 2. "The will can't be changed once it is written." 3. "You will have to discuss the issue with your lawyer." 4. "A living will should be reviewed yearly with your physician."

4. "A living will should be reviewed yearly with your physician." Rationale: The client should discuss the living will with the physician, and it should be reviewed annually to ensure that it contains the client's current wishes and desires. Options 1 and 2 include inaccurate information. Option 3 is not an appropriate response and places the client's question on hold.

A licensed practical nurse (LPN) is reinforcing instructions given by a registered nurse (RN) to a client about how to take medications after discharge from the hospital. The LPN should use which of the following approaches to best ensure safe administration of medication in the home? 1. Show the client the proper way to take prescribed medications 2. Tell the client to double up on medications if a dose has been missed 3. Count the number of pills remaining in the prescription bottle once a week 4. Allow the client to verbalize and demonstrate correct administration procedure

4. Allow the client to verbalize and demonstrate correct administration procedure Rationale: The most effective method of teaching to ensure safe self-administration of medications in the home setting is to have the client verbalize and also demonstrate how to take medications. This ensures that the client has both the knowledge and the physical ability to comply with medication therapy. Option 1 is useful early in the teaching or learning process but is not the best method because it does not allow the client to demonstrate his or her own ability. Option 2 is incorrect because it is dangerous and incorrect statement. Option 3 is unrealistic and does not enhance self-care.

A licensed practical nurse (LPN) is reinforcing teaching done by the registered nurse (RN) with a client who has been diagnosed with endocarditis. The LPN explains that it is important for this client to use an electric razor rather than a straight razor for shaving because of which of the following? 1. An electric razor can be sanitized more easily 2. Straight razors harbors too many microorganisms 3. The client is at a higher risk for infection from any nick or cut 4. Any cuts or skin injury should be avoided while taking anticoagulants

4. Any cuts or skin injury should be avoided while taking anticoagulants Rationale: Clients with endocarditis are at risk for developing thrombi along the walls of the heart, which could become emboli leading to stroke. For this reason, clients with endocarditis are treated with anticoagulant therapy to prevent thrombus formation. Clients on anticoagulants should implement measures to prevent injury and subsequent bleeding, The other options are incorrect because infection rather than bleeding is their primary focus.

A nurse is observing a nursing assistant talking to a client who is hearing impaired. The nurse should intervene if which of the following were performed by the nursing assistant during communication with the client? 1. The nursing assistant is speaking in a normal tone 2. The nursing assistant is speaking clearly to the client 3. The nursing assistant is facing the client when speaking 4. The nursing assistant is speaking directly into the impaired ear

4. The nursing assistant is speaking directly into the impaired ear Rationale: When communicating with a hearing impaired client, the nurse should speak in a normal tone to the client and should not shout. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express the statement differently. Moving closer to the client and toward the better ear may improve communication, but the nurse should avoid talking directly into the impaired ear.

A nurse employed in a clinic is assisting in the care of a client with diabetes mellitus who is 36 weeks' pregnant. The results of three previous weekly nonstress tests have been reactive. This week the test was nonreactive after 40 minutes. The nurse should expect that the physician will prescribe which of the following to safely monitor this client? 1. A contraction stress test 2. Admission to the hospital for continuous fetal monitoring 3. Admission to the hospital for immediate induction of labor 4. A follow-up appointment in 3 days to repeat the nonstress test

1. A contraction stress test Rationale: A nonreactive test requires further follow-up evaluation, indicating the need for a contraction stress test. To send the client home for 3 days could place the fetus in jeopardy. Hospitalizing the client for either induction of labor or continuous fetal monitoring would be a premature intervention without further diagnostic test data.

A client with possible renal disease is scheduled to undergo diagnostic testing by intravenous pyelogram (IVP). To ensure client safety, the nurse should be certain to collect data from this client about a history of which of the following? 1. Allergy to shellfish 2. Family incidence of renal disease 3. Frequent and chronic antibiotic use 4. Long-term use of diuretic medications

1. Allergy to shellfish Rationale: A client undergoing diagnostic testing that uses a contrast medium such as IVP should be questioned about allergy to shellfish, seafood, or iodine. This would identify a potential allergic reaction to the contrast dye that may be used in this test. The other items are useful as part of the general health history but are not as critical as the allergy determination.

A prenatal client who has acquired the sexually transmitted virus Condyloma acuminatum (human papilloma virus) asks the nurse to explain again the treatment for the infection. The nurse should reinforce additional information about which of the following safe treatments with this client? 1. Laser therapy 2. Interferon therapy 3. Cytotoxic medications 4. No therapy is available

1. Laser therapy Rationale: For the pregnant client, laser therapy is the most effective method of destroying the virus. This therapy is localized, whereas medications (which are considered toxic to the fetus) would have a systemic effect. The primary neonatal effect of the virus is respiratory or laryngeal papillomatosis, although the exact route of perinatal transmission is unknown. Options 2, 3 and 4 are incorrect.

A nurse is caring for an older client who had a hip pinned after being fractured. In planning nursing care, the nurse should avoid which of the following to minimize the chance for further injury? 1. Leaving the side rails down 2. Keeping the call bell in reach 3. Answering the call bell promptly 4. Ensuring that the night-light is working

1. Leaving the side rails down Rationale: Safe nursing actions intended to prevent injury to the client include keeping the side rails up, keeping the bed in low position, and providing a call bell that is within the client's reach. Responding promptly to the client's use of the call light minimizes the chance that the client will try to get up alone, which could result in a fall. Night-lights are built into the lighting systems of most facilities, and these bulbs should be routinely checked to ensure that they are working.

A nurse is assisting in preparing a plan of care for a client being admitted to the hospital for insertion of a cervical radiation implant. Which safe activity should the nurse suggest for this client following insertion of the implant? 1. Maintain bed rest 2. Out of bed in a chair only 3. Elevate the head of the bed 45 degrees 4. Maintain the client in the side lying position

1. Maintain bed rest Rationale: The client with a cervical radiation implant should be maintained on bed rest in the dorsal position to prevent movement of the radiation source. The head of the bed is elevated to a maximum of 10 to 15 degrees for comfort. Turning the client on the side is avoided. If turning is absolutely necessary, a pillow is placed between the knees and, with the body in straight alignment the client is logrolled.

A nurse is preparing to give an intramuscular (IM) injection that is irritating to the subcutaneous tissues. The drug reference recomends that it be given using the Z-track technique. Which of the following procedural steps would cause tracking the medication through the subcutaneous tissues? 1. Massaging the site after injecting the medication 2. Retracting the skin to the side before piercing the skin with the needle 3. Attaching a new sterile needle to the syringe after drawing up the medication 4. Preparing a 02.mL air lock in the syringe after drawing up the medication

1. Massaging the site after injecting the medication Rationale: The Z-track variation of the standard IM technique is use to administer IM medications that are highly irritating to subcutaneous and skin tissues. Attaching a new sterile needle is done so that the new needle will not have any medication adhering to the outside that could be irritating to the tissues. Preparing an air lock keeps the needle clean of medication on insertion and, as the air is injected behind the medication, will provide a seal at the point of insertion to prevent tracking through the subcutaneous tissues. The site should not be massaged because this can lead to tissue irritation.

A nurse employed in a physician's office is asked to check the client who is at low risk for contracting tuberculosis for the results of the purified derivative (PPD) implanted 72 hours previously. The nurse reads the PPD as measuring 11 mm induration in diameter. Which action should the nurse take next? 1. Notify the physician 2. Ask the client for permission to repeat the test 3. Document the normal finding in the client's record 4. Tell the client to make an appointment with a pulmonologist

1. Notify the physician Rationale: An area of induration that measures 10 mm is considered a positive reading and indicates exposure to tuberculosis (TB). The nurse who observes a positive PPD reading notifies the physician immediately. The physician would then order a chest x-ray to determine whether the client has clinically active tuberculosis or old, healed lesions. A sputum culture would then be done to confirm a diagnosis of active TB. Option 3 is incorrect because the reading is not a normal finding. Option 2 is incorrect because the test results are positive. The physician, not a nurse would request a consultation with a pulmonologist.

A nurse who is assisting a physician with insertion of a Miller-Abbott tube should do which of the following to ensure a safe environment and decrease the client's risk of aspiration? 1. Place the client in a high-Fowler's position 2. Assist with inserting the tube with the balloon inflated 3. Instruct the client to bear down if there is an urge to gag 4. Ask the client to cough when the tube reaches the nasopharynx

1. Place the client in a high-Fowler's position Rationale: A miller-Abbott tube is a nasoenteric tube used to correct a bowel obstruction and decompress the intestine. A high-Fowler position decreases the risk of aspiration if vomiting occurs. A physician inserts the tube with the balloon deflated in a manner similar to that used with a nasogastric tube. The client usually sips water to facilitate passage of the tube through the correct nasopharynx and esophagus. Options 2, 3 and 4 are incorrect actions.

A nurse is collecting information from a client about the client's suicide risk. The nurse should ask the client which most significant question? 1. "Why do you want to hurt yourself?" 2. "Do you have a plan to commit suicide?" 3. " Has anyone in your family committed suicide?" 4. Can you describe how you are feeling right now?"

2. "Do you have a plan to commit suicide?" Rationale: When collecting information about suicide risk, the nurse must determine if the client has a suicide plan. Clients who have a definitive plan pose a greater risk for suicide. Options 1, 3 and 4 do not directly provide this information.

A physician orders a 12-lead electrocardiogram (CG) to be performed on a client. The client is concerned about the safety of the test, and the nurse provides information to the client. Which of the following would indicate that the client understands the test? 1. "I cannot breathe while the ECG is running." 2. I should lie still while the ECG is being done." 3. When the ECG begins, I must take a deep breath." 4. If I move when the ECG begins I will be shocked."

2. "I should lie still while the ECG is being done." Rationale: good contact between the skin and electrodes is necessary to obtain a clear 12-lead ECG printout. Therefore the electrodes are placed on the flat surfaces of the skin just above the ankles and wrists. Movement may cause a disruption in that contact and artifact, which makes the ECG printout difficult to read. The client does not have to hold the breath or take a deep breath during the procedure. The client should be reassured that the procedure will not produce a shock.

A new nurse graduate asks another licensed practical nurse (LPN) about the need to obtain professional liability insurance. The appropriate response by the LPN is: 1. "The hospital insurance covers your actions." 2. "Nurses should have their own malpractice insurance." 3. "It is very expensive, and you really don't need it since the hospital covers you." 4. "Lawsuits are filed against physicians and the hospital, so you are safe not to obtain it."

2. "Nurses should have their own malpractice insurance." Rationale: Nurses need their own liability insurance for protection against malpractice lawsuits. Nurses erroneously assume that they are protected by an agency's professional liability policies. Usually when a nurse is sued, the employer is also sued for the nurse's actions or inactions. Even though this is the norm, nurses are encouraged to have their own malpractice insurance.

A rehabilitation center nurse is planning the client assignments for the day. Which of the following clients should the nurse assign to the nursing assistant? 1. A client who had a below-the-knee amputation 2. A client on a 24-hour urine collection who is on strict bed rest 3. A client scheduled for transfer to the hospital for an invasive diagnostic procedure 4. A client scheduled to be transferred to the hospital for coronary artery bypass surgery

2. A client on a 24-hour urine collection who is on strict bed rest. Rationale: The nurse is legally responsible for client assignments and must assign tasks based on the guidelines of nursing practice acts and the job description of the employing agency. A client who had a below-the-knee amputation, is scheduled for an invasive procedure, or is scheduled to be transferred to the hospital for coronary artery bypass surgery has both physiological and psychological needs. The nursing assistant has been trained to care for a client on bed rest and urine collections. The nurse provides instructions, but the tasks required are within the role of a nursing assistant.

An adolescent asks a nurse about the procedure to become an organ donor. The nurse most accurately tells the adolescent that: 1. Written consent is never required to become a donor 2. A donor must be 18 years or older to provide consent 3. An individual who is at least 16 years of age can sign to become a donor 4. The family is responsible for making the decision about organ donation at the time of death

2. A donor must be 18 years or older to provide consent Rationale: Any person 18 years of age or older may become an organ donor by indicating his or her consent in writing. In the absence of appropriate documentation, a family member or legal guardian may authorize donation of the decedent's organs.

A client has an order for valproic acid (Depakene) 250 mg once daily. To maximize the client's safety, the nurse plans to schedule the medication: 1. With lunch. 2. At bedtime. 3. After breakfast. 4. Before breakfast.

2. At bedtime Rationale: Valproic acid is an anticonvulsant that causes central nervous system (CNS) depression. Its side effects include sedation, dizziness, ataxia and confusion. When the client is taking this medication as a single dose, administering it at bedtime negates the risk of injury from sedation and enhances client safety.

A nurse is caring for a client who is receiving a dose of an intramuscular antibiotic. The nurse enters the client's room to administer the prescribed antibiotic, and the client tells the nurse that the medication burns and that he does not want to receive it. The nurse tells the client that the medication is necessary and administers the medication. Which of the following can the client legally charge as a result of the nursing action? 1. Assault 2. Battery 3. Negligence 4. Invasion of privacy

2. Battery Rationale: An assault occurs when a person puts another person in fear of a harmful or offensive contact. For this intentional tort to be actionable the victim must be aware of the threat of harmful or offensive contact. Battery is the actual contact with one's body. Negligence involves actions below the standards of care. Invasion of privacy occurs when the individual's private affairs are unreasonably invaded. In this event, the nurse can be charged with battery because the nurse administers a medication that the client has refused.

A nurse is assisting in planning the discharge of a client with chronic anxiety and assists in selecting the goals that will promote a safe environment at home. The appropriate maintenance goal should focus on which of the following? 1. Ignoring feelings of anxiety 2. Identifying anxiety-producing events 3. Continuing contact with a crisis counselor 4. Eliminating all anxiety from daily events

2. Identifying anxiety-producing events Rationale: Recognizing events that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing events, and this option does not encourage the development of internal strengths. Ignoring feelings will not resolve anxiety. It is impossible to eliminate all anxiety from daily activities.

A client with depression who was admitted to the psychiatric unit the previous day suddenly begins smiling and stating that the current episode of depression has lifted. The client continues to be talkative and engages in conversation with other clients on the unit. The licensed practical nurse (LPN) consults with the registered nurse knowing that which of the following changes should be made to the client's treatment plan? 1. Allow increased "in room" activities 2. Increase the level of suicide precautions 3. Allow the client to spend time off the unit 4. Reduce the dosage of antidepressant medication

2. Increase the level of suicide precautions Rationale: A depressed client hospitalized for only 1 day is unlikely to have a dramatic cure. A sudden elevation in mood probably indicates that the client has decided to harm himself or herself. An increase in the level of suicide precautions is indicated to keep the client safe. The other options are not indicated (option 1) or could place the client at increases risk (options 3 and 4).

A client is admitted to a long-term care facility with a diagnosis of Parkinson's disease. The nurse gives information about the client's condition to a visitor assumed to be a family member. The nurse has violated which legal concept of the nurse-client relationship? 1. Incompetency 2. Invasion of privacy 3. Communication techniques 4. Teaching/Learning principles

2. Invasion of privacy Rationale: Discussing a client's condition without the client's permission violates the client's right and places the nurse in legal jeopardy. This is an invasion of privacy and affects client's confidentiality. Incompetence could lead to negligence, but this legal concept is not related to the subject identified in the question. Communication techniques relate to the nurse-client relationship. Teaching/learning principles are considered concepts of standard practice.

A nurse is carrying out an order to obtain a sputum sample, which must be obtained using the saline inhalation method. The nurse guides the client in using the nebulizer safely and effectively by encouraging the client to do which of the following? 1. Hold the nebulizer under the nose 2. Keep the lips closed lightly over the mouthpiece 3. Keep the lips closed tightly over the mouthpiece 4. Alternate one vapor breath with one breath from room air

2. Keep the lips closed lightly over the mouthpiece Rationale: Inhaling vaporized saline is an effective means to assist a client to cough productively because the vapor condenses on respiratory mucosa, stimulating the cough reflex and the expectoration of secretions. The nurse tells the client to hold gentle pressure between the lips and the mouthpiece. It is not necessary to form a tight seal. The client inhales vaporized saline with each breath until coughing results. The nebulizer is not held under the nose.

A nurse is assisting in providing emergency treatment for a client in ventricular tachycardia. The licensed practical nurse understands that which action by the registered nurse provides for the safest environment during a defibrillation attempt? 1. Places no lubricant on the paddles 2. Performs a visual and verbal check of "all clear" 3. Holds the client's upper torso stable while the defibrillation is performed 4. Hands the charged paddles separately to the person performing the defibrillation

2. Performs a visual and verbal check of "all clear" Rationale: Safety during defibrillation is essential for preventing injury to the client and to the personnel assisting with the procedure. The person performing the defibrillation ensures that all personnel are standing clear of the bed by a verbal and visual check of "all clear." Charged paddles should never be handed to other personnel. For the shock to be effective, some type of conductive medium (lubricant, gel) must be placed between the paddles and the skin. The client is not touched during the defibrillation procedure.

A licensed practical nurse (LPN) is assisting a registered nurse (RN) to develop a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which of the following does the LPN suggest be included in the client's plan of care? 1. Limit visitor's time to 60 minute visits 2. Place a radiation sign on the door of the client's room 3. Place the client in a private room close to the nurses' station 4. Reinsert the implant into the vagina immediately if it becomes dislodged

2. Place a radiation sign on the door of the client's room Rationale: The client's room should be marked with appropriate signs stating the presence of radiation. Visitors are limited to 30 minutes. The client should be placed in a private room at the end of the hall because this location provides less a chance of radiation exposure to others. A lead container and long-handled forceps should be kept in the client's room at all times during internal radiation therapy. If the implant becomes dislodged, the nurse should pick it up with long-handled forceps and place it in the lead container. It is not reinserted by the nurse.

A 2 month-old is admitted to the hospital. The nurse should take which of the following actions to maintain the infant's safety and to reduce the risk of sudden infant death syndrome (SIDS)? 1. Make sure that only plastic bottles and toys are used 2. Place the infant in a supine position in preparation for sleep 3. Take the pacifier out of the mouth before the infant falls asleep 4. Cover the crib with netting when the child is not being directly observed

2. Place the infant in a supine position in preparation for sleep Rationale: The American Academy of Pediatrics recommends the supine position for sleep to reduce the risk of SIDS. Plastic bottles and toys are not needed yet because a 2 month-old cannot hold them. Pacifiers are considered safe and appropriate at this age. Safety netting is not necessary for a 2 month-old because the infant cannot roll over or stand alone.

A client who is admitted to the labor and delivery unit in active labor has active genital herpes lesions present in the genital tract. The licensed practical nurse should reinforce teaching done by the registered nurse about which of the following immediate plans for the client? 1. Placement on protective isolation 2. Preparation for a cesarean delivery 3. Preparation for spontaneous vaginal delivery 4. Imminent artificial rupture of the membranes

2. Preparation for a cesarean delivery Rationale: Cesarean delivery reduces the risk of neonatal infection with a mother in labor who has either herpetic genital lesions or ruptured membranes. Options 3 and 4 would expose the fetus to the virus. Standard Precautions are necessary, not protective isolation.

A psychotic client is belligerent and agitated, making aggressive gestures and pacing in the hallway. To ensure a safe environment, which of the following is the nurse's highest priority? 1. Assist other staff in restraining the client 2. Provide safety for the client and other clients on the unit 3. Provide comfort and consolation to other clients on the unit 4. Ask the client politely to calm down and regain control over his or her behavior

2. Provide safety for the client and other clients on the unit Rationale: A psychotic client who is out of control may require seclusion to ensure the safety of the client and other clients in the unit. The correct option is the only one that addresses the safety needs of both the client and others. Options 1 and 3 do not provide for the client's safety needs or rights, respectively. In addition, specific policies and guidelines must be followed with regard to restraining a client. Option 4 may be ineffective and does not address the safety needs of others in the unit.

A nurse is planning to reinforce instructions to a client with chronic vertigo about safety measures to prevent worsening of symptoms or injury. Which safety instruction should the nurse provide to the client? 1. Turn the head slowly when spoken to 2. Remove throw rugs and clutter in the home 3. Drive at times when the client does not feel dizzy 4. Go to the bedroom and lie down when vertigo is experienced

2. Remove throw rugs and clutter in the home Rationale: The client with chronic vertigo should avoid driving and using public transportation. The sudden movements involved in each could precipitate an attack. To further prevent vertigo attacks, the client should change position slowly and should turn the entire body, not just the head, when spoken to. If vertigo does occur, the client should immediately sit down or grasp the nearest piece of stable furniture. The client should maintain a clutter-free home with throw rugs removed because the effort of regaining balance after slipping could trigger vertigo.

An adult client is brought to the emergency room by an ambulance after being hit by a car. The client is unconscious and in shock. A perforated spleen is suspected, and emergency surgery is required immediately to save the client's life. No family members are present. In regard to informed consent for the surgical procedure, the nurse understands that which of the following is the best nursing action? 1. Ask the hospital chaplain to sign the consent form 2. Transport the client to the operating room immediately 3. Call the nursing supervisor to initiate a court order for the surgical procedure 4. Call a family member to obtain telephone consent before the surgical procedure

2. Transport the client to the operating room immediately Rationale: Generally there are only two instances in which the informed consent of an adult is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. It is inappropriate to ask the hospital chaplain to sign the consent form. Requesting that the nursing supervisor initiate a court order for the surgical procedure delays the necessary life-saving intervention. Although the family needs to be notified, calling a family member to obtain telephone consent before the surgical procedure also delays necessary life-saving intervention.

A nurse administers a fatal dose of digoxin (Lanoxin) to a client. During the subsequent investigation of error, it is determined that the nurse did not note the client's heart rate of 45 beats per minute before administering the medication. Failure to adequately collect all data in this event is addressed under which function of the Nurse Practice Act? 1. Defining the specific educational requirements for licensure in the state 2. Describing the scope of practice of licensed and unlicensed care providers 3. Identifying the process fro disciplinary action if standards of care are not met 4. Recommending specific terms of incarceration for nurses who violate the law

3. Identifying the process for disciplinary action if standards of care are not met Rationale: In this event, acceptable standards of care were not met (the nurse failed to adequately assess the client before administering a medication). Option 3 refers specifically to the event described in the question. Options 1, 2 and 4 do not relate to the event described in the question.

A nurse employed in a long-term care facility has planned a get-together for clients and their families to celebrate the birthday of a client who is 100 years old. During the party, the nurse takes pictures of some of the clients and plans to develop the pictures and submit the pictures to the local newspaper. Which client right has the nurse violated? 1. Assault 2. Battery 3. Invasion of privacy 4. False imprisonment

3. Invasion of privacy Rationale: Invasion of privacy takes place when an individual's private affairs are unreasonably invaded. Taking photographs of a client is an example of such a violation. Telling the client that he or she cannot leave the hospital constitutes an example of false imprisonment. Threatening to place a client in restraints is an example of an assault. Performing a procedure without consent is an example of battery.

A nurse is assigned to care for a client who has returned to the nursing unit after an oral cholecystogram. At this point in time, the nurse should question which of the following physician's orders in the medical record? 1. Assess for nausea and vomiting 2. Monitor the client's hydration status 3. Maintain a clear liquid status for 72 hours 4. Monitor the client for abdominal discomfort

3. Maintain a clear liquid status for 72 hours Rationale: The client should be able to resume the usual diet once the nurse assured is assured the client that the client's gastrointestinal (GI) function is normal. It is not necessary to keep the client on clear liquids for 72 hours after the procedure. The nurse would monitor the client for complaints of GI discomfort and nausea and vomiting. The nurse would also assess the client's hydration status as part of routine care for the client undergoing a GI diagnostic test.

The nurse is administering medications to a client and administers a dose of methyldopa (Aldomet) 250 mg orally instead of the prescribed 125 mg dose. The nurse discovers the error when documenting that the medication has been administered. Which of the following is an inappropriate nursing action regarding the incident? 1. Complete an incident report 2. Monitor the client's blood pressure 3. Make a copy of the incident report for the physician 4. Document a complete entry in the client's record concerning the incident

3. Make a copy of the incident report for the physician Rationale: An incident report needs to be completed whenever an unusual occurs. The incident report is confidential and privileged information and should not be copied, placed in the chart, or have any reference made to it in the client's record. A complete entry in the client's record should be made concerning the incident. The incident report is not a substitute for such an entry. The client's blood pressure should be monitored because this medication is an antihypertensive. The physician is notified.

A client who has been admitted to the mental health unit with obsessive compulsive disorder repeatedly cleans the bathroom fixtures. The client has become enraged and has started to bite and kick the roommate for occupying the bathroom. Which of the following actions should the nurse take first? 1. Physically restrain the client 2. Notify the risk management department 3. Provide a safe environment for both clients 4. Administer a medication to provide chemical restraint

3. Provide a safe environment for both clients Rationale: The first action of the nurse is to provide an environment that is safe for both clients. This may take a variety of forms, depending on the individual circumstance, agency protocols, and written physician orders. Seclusion, chemical restraint, and physical restraint are used only when alternative and less restrictive measures are not effective in controlling the client's behavior.

A nurse is assisting in the admission of a postoperative client from the postanesthesia care unit to the surgical nursing unit. The nurse should do which of the following for the safety of the client? 1. Ask the client to slide from the stretcher to the bed 2. Move the client rapidly from the stretcher to the bed 3. Put the bed rails up after moving the client from the stretcher 4. Uncover the client before transferring him or her from the stretcher to the bed

3. Put the bed rails up after moving the client from the stretcher Rationale: Because the client may still be experiencing residual effects of anesthesia, the nurse should raise the side rails after transferring the client from the stretcher to the bed. It is not realistic to ask the client to slide from the stretcher to the bed because of the effects of anesthesia and postoperative pain. Hurried movements and rapid changes in position should be avoided since these predispose the client to hypotension. During the transfer of the client after surgery, the nurse should avoid exposing the client because of potential heat loss, respiratory infection and shock.

A nurse has administered a dose of diazepam (Valium) to the client. The nurse should take which most important action before leaving the client's room? 1. Draw the shades closed 2. Give the client a bedpan 3. Put up the side rails on the bed 4. Turn the volume on the television set down

3. Put up the side rails on the bed Rationale: Diazepam is a sedative/hypnotic with anticonvulsant and skeletal muscle relaxant properties. The nurse should institute safety measures before leaving the client's room to ensure that the client does not injure himself or herself. The most frequent side effects of this medication are dizziness, drowsiness and lethargy. Therefore the nurse puts the side rails up on the bed before leaving the room to prevent falls. Options 1, 2 and 4 may be helpful measures that provide a comfortable, restful environment; however, option 3 is the only one that provides for the client's safety needs.

A nurse working in a long-term care facility responds after hearing someone calling, "Help, the bed is on fire!" On entering the room, the nurse finds an older client slapping at the flames on the bedspread with a pillow. Both hands have been burned. Which action should the nurse take first? 1. Pull the nearest fire alarm 2. Close the door to the room 3. Remove the client from the room 4. Run to get the nearest fire extinguisher

3. Remove the client from the room Rationale: In a fire emergency, the steps to follow use the acronym RACE. The first step is to remove the victim. The next steps are: activate the alarm, contain the fire, and then extinguish as needed. This is a universal standard that may be applied to any type of fire emergency. Option 3 is correct because it removes the victim from the area. Option 1 would be the next step (alarm). The fire is next contained (option 2) and then extinguished (option 4).

A nurse overhears a client ask the physician if the client the results of a biopsy indicated cancer. The physician tells the client that the results have not returned, when in fact the physician is aware that the results of the biopsy indicated the presence of malignancy. The nurse is upset that the physician has not shared the results with the client and tells another nurse that the physician has lied to the client and that the physician probably lies to all the clients. Which legal tort has the nurse violated by this statement? 1. Libel 2. Assault 3. Slander 4. Negligence

3. Slander Rationale: Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group. Although the physician may be aware of the biopsy results, the physician decides when it is best to share such a diagnosis with the client.

A nurse is assigned to care for a client with Parkinson's disease who has recently begun taking L-dopa (levodopa). Which of the following is most important to check before ambulating the client? 1. The client's history of falls 2. Assistive devices used by the client 3. The client's postural (orthostatic) vital signs 4. The degree of intention tremors exhibited by the client

3. The client's postural (orthostatic) vital signs Rationale: Clients with Parkinson's disease are at risk for postural (orthostatic) hypotension from the disease. This problem worsens when L-dopa is introduced because the medication can also cause postural hypotension, thus increasing the client's risk for falls. Although knowledge of the client's use of assistive devices and history of falls is helpful, it is not the most important piece of data based on the information in this question. Clients with Parkinson's disease generally have resting rather then intention tremors.

A nurse is collecting data about the lethality risk of a suicidal client. Which of the following is the best question for the nurse to ask the client? 1. "Do you have a death wish?" 2. "Do you wish your life was over?" 3. "Do you ever think about ending it all?" 4. "Have you ever thought of killing yourself?"

4. "Have you ever thought of killing yourself?" Rationale: A lethality assessment requires direct communication between the client and nurse. It is important to provide a question that is directly related to lethality. Options 1, 2 and 3 do not directly address the subject of the question. Option 4, is the most direct option.

A client with a synthetic cast on the right leg tells the nurse that he wants to take a shower. Based on the review of the data related to the injury and type of cast, which of the following is the best response to ensure a safe environment? 1. "The cast padding will never dry." 2. "It may lead to a serious problem." 3. "Hot water may soften the synthetic cast." 4. It is not safe for you to shower at this time."

4. "It is not safe for you to shower at this time." Rationale: It may be unsafe for a client to shower with a cast the leg because the client could slip and fall. Water does not damage the synthetic cast; however, the client should know that it may take a while for the cast padding to dry. Water may soften a plaster cast but has no effect on a synthetic cast. A shower will not cause an infection.

Which statement made by a nursing student indicates an understanding of the concepts associated with suicide and suicide intentions? 1. "Only psychotic individuals commit suicide." 2. "Suicide attempts are just attention-seeking behaviors." 3. "Suicide runs in the family, so there is nothing that health care personnel can do about it." 4. "Many individuals who really do kill themselves have talked about their intentions to others."

4. "Many individuals who really do kill themselves have talked about their intentions to others." Rationale: Most people who commit suicide have given definite clues or warnings about their intentions. The individual who is suicidal is not necessarily psychotic or even mentally ill. A suicide attempt is not an attention-seeking behavior, and each act should be taken seriously. Suicide is not an inherited condition; it is an individual condition.

A nurse has reinforced instructions to a parent regarding the safe methods to prevent Lyme disease. Which statement made by a parent would indicate the need for additional instructions? 1. "We should wear hats when we go on our hiking trip." 2. "Wearing long-sleeved tops and long pants is important." 3. "We should wear closed shoes and socks that can be pulled over our pants." 4. "We should avoid the use of insect repellents because they will attract the ticks."

4. "We should avoid insect repellents because they will attract the ticks." Rationale: To prevent Lyme disease, individuals should be instructed to use insect repellent on the skin and clothes in areas where ticks are likely to be found. Long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn. If possible, heavily wooded areas or areas with thick underbrush should be avoided. Socks can be pulled up and over pant legs to prevent ticks from entering under clothing.

A nurse is assigned to care for a client who sustained a burn injury. The nurse reviews the physician's orders and should question the registered nurse about which order? 1. Monitor weight daily 2. Monitor urine output hourly 3. Maintain the nasogastric tube to intermittent suction 4. Administer morphine sulfate intramuscularly every 3 hours as needed for pain

4. Administer morphine sulfate intramuscularly every 3 hours as needed for pain Rationale: Oral, subcutaneous and intramuscular routes for administering medications are contraindicated in the burned client because of the poor absorption factor. When fluid balance is stabilized, oral narcotic agents can be used. Options 1, 2 and 3 are all appropriate interventions for the client with a burn.

An older client who has not been hospitalized previously is extremely anxious after hospital admission. To provide a safe environment for the client and minimize the stress of hospitalization, the nurse should do which of the following? 1. Keep visitors to the minimum number possible 2. Keep the door open and room lights on at all times 3. Admit the client to a room far away from the nurse's station 4. Allow the client to have as many choices related to care as possible

4. Allow the client to have as many choices related to care as possible Rationale: Several general interventions will reduce the hospitalized client's level of stress. These include acknowledging the client's feelings, offering information, providing social support, and letting the client have control over choices related to care. Options 1 and 3 could increase anxiety, whereas option 2 could add to the disruption created by the hospitalization and interfere with the client's sleep pattern.

A nurse is carrying out an order for a 24-hour urine collection for a client with a suspected renal disorder. Which of the following actions should the nurse avoid to ensure proper collection technique? 1. Refrigerate the container or place it on ice 2. Save all voidings after the first one in the 24-hour period 3. Ask the client to void at the end time, and add this specimen to the container 4. Ask the client to void at the start time, and place this specimen in the container

4. Ask the client to void at the start time, and place this specimen in the container Rationale: To collect a 24-hour urine specimen, the nurse should ask the client to void at the beginning of the collection period and discard the urine sample. This is done because the urine in that voiding has been in the bladder for an unknown period of time. All subsequent voided urine is saved in a container, which is placed on ice or refrigerated. The nurse should ask the client to void at the finish time and add this sample to the collection. The nurse then labels the container, places it on fresh ice, and sends it to the laboratory immediately.

A nurse assisting in the care of a client who has been in a coma for more than a year is told by the physician to stop the tube feeding that is providing sustenance to the client. The nurse, who is aware of the legal basis needed for carrying out the order, first determines whether which of the following requirements has been met? 1. Institutional Ethics Committee approval 2. A court order to discontinue the treatment 3. A written order by the physician to remove the tube 4. Authorization by the family to discontinue the treatment

4. Authorization by the family to discontinue the treatment Rationale: The family or a legal guardian can make treatment decisions, generally in collaboration with physicians, other health care workers, and other trusted advisors. The nurse first checks for family authorization to discontinue the treatment. Next, option 3 would be appropriate. Although options 1 and 2 may be necessary in some events, these options are not the first actions in this event.

A 22 year-old client who was struck by a car while jogging, is brought to the emergency room by the ambulance team. Emergency measures are instituted but are unsuccessful. The client's fiancee is with the client and tells the nurse that the client is an organ donor. In anticipation that the client's eyes will be donated, which of the following should the nurse plan to implement initially? 1. Ask the fiancee to obtain the client's will from the lawyer 2. Call the National Eye Bank to confirm that the client is a donor 3. Position the deceased client supine and place dry sterile dressings over the eyes 4. Elevate the head of the bed, close the deceased client's eyes, and place a small ice pack on the eyes

4. Elevate the head of the bed, close the deceased client's eyes, and place a small ice pack on the eyes Rationale: When corneal donation is anticipated, the head of the bed is elevated, the deceased client's eyes are closed, and a small ice pack is placed on the client's eyes. Within 2 to 4 hours the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours. Options 1 and 3 are incorrect actions. Option 2 is not an initial action.

An older client with diabetes mellitus is vomiting because of gastroenteritis. The nurse should do which of the following to maintain oral intake to safely minimize the risk of dehydration? 1. Give only sips of water until the client is able to tolerate solid foods 2. Withhold all food and fluids until vomiting has ceased for at least 8 hours 3. Restrict the client to clear liquids for at least 3 days to allow for bowel rest 4. Encourage the client to drink up to 8 to 12 ounces of fluid every hour while awake

4. Encourage the client to drink up to 8 to 12 ounces of fluid every hour while awake Rationale: Small amounts of fluid may be tolerated even when vomiting is present. The client should be offered up to 8 to 12 ounces of liquid containing both glucose and electrolytes hourly. The diet should be advanced to a regular diet as soon as it is tolerated and should include a minimum of 100 to 150 g of carbohydrates daily. Options 1, 2 and 3 are incorrect actions because they will not maintain adequate oral intake.

A physical assessment of the suicidal client is performed on admission to the inpatient unit. The nurse reviews the findings and recognizes that this is an important part of the admission process because it alerts the nurse to: 1. Baseline data 2. Abnormalities 3. Existing medical problems 4. Evidence of physical self-harm

4. Evidence of physical self-harm Rationale: The physical assessment of a suicidal client should be thorough and should focus on the evidence of self-harm or the formulation of a plan for the suicide attempt. Although all of the options are correct, option 4 is the most appropriate for the suicidal client. Clients with a history or evidence of self-harm are greater suicide risks.

An extremely angry and aggressive client in the mental health inpatient unit has been placed in restraints. When working with this client, the nurse should suggest removal of the restraints when the client: 1. Has been sedated and is still experiencing its effects 2. Divulges all of the reasons for the aggressive behavior 3. Apologizes and tells the nurse that it will not happen again 4. Initiates no aggressive acts for an hour after the release of two leg restraints

4. Initiates no aggressive acts for an hour after the release of two leg restraints Rationale: The best indicator that the client's behavior is under control is when the client refrains from aggression after being partially releases from the restraints. Restraints are initially placed around the waist, wrists, and ankles. The ankle restraints are removed first, one at a time, at regular intervals. The wrist and waist restraints are removed together when the client continues to exhibit nonaggressive behavior.

A nurse assists in developing a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which of the following will the nurse suggest to include in the client's plan of care? 1. Limit visiting time to 60 minutes per visit 2. Place the client in a private room near the nurse's station 3. Reinsert the implant into the vagina immediately if it becomes dislodged 4. Place a sign on the door of the client's room indicating the need to speak to the nurse before entering

4. Place a sign on the door of the client's room indicating the need to speak to the nurse before entering Rationale: the client's room should be marked with appropriate signs stating the need to speak to the nurse before entering because of the risk of exposure to radiation when in the client's room. The client should be placed in a private room at the end of the hall because this location provides less chance of radiation exposure to others. A lead container and long handled forceps should be kept in the client's room at all times during internal radiation therapy. If the implant becomes dislodged, the nurse should be pick up the implant with long handled forceps and place it in the lead container. The nurse does not reinsert it. Visiting time is limited to 30 minutes per visit.

A nurse must give an injection to a client with acquired immunodeficiency syndrome (AIDS). The nurse does which of the following after giving the injection? 1. Breaks the needle and discards it 2. Recaps the needle and discards the syringe in the disposal unit 3. Places the uncapped needle and syringe in a labeled cardboard box 4. Places the uncapped needle and syringe in a labeled, rigid plastic container

4. Places the uncapped needle and syringe in a labeled, rigid plastic container Rationale: Standard precautions include specific guidelines for handling sharps and needles. Needles should not be recapped, bent, broken or cut after use; they should be disposed of in a labeled, impermeable container specifically used for this purpose. Needles should not be discarded in cardboard boxes because they could puncture the cardboard, causing a needlestick injury. Needles should never be left lying around after use.

A client who does not have an artificial airway has a new order for a sputum culture. The nurse should avoid doing which of the following to obtain a suitable specimen? 1. Obtaining the specimen early in the morning 2. Having the client take deep breaths before coughing 3. Asking the client to rinse the mouth before expectoration 4. Placing the culture container lid face down on the bedside table

4. Placing the culture container lid face down on the bedside table Rationale: The lid would be contaminated if it is placed face down on the bedside table, which could lead to inaccurate test results. The client should rinse the mouth or brush the teeth before specimen collection to avoid contaminating the specimen. The client should take deep breaths before expectoration for the best sputum production. The specimen is optimally obtained early in the morning because sputum has a longer amount of time to collect in the airways during sleep.

A nurse assigned to care for a 4-week-old infant who is scheduled for a pyloromyotomy. The nurse plans to do which of the following when caring for the infant? 1. Restrain the infant in a high chair 2. Feed the infant in a lying-down position 3. Feed the infant 1 ounce of formula every hour 4. Position the infant prone with the head of the bed elevated

4. Position the infant prone with the head of the bed elevated Rationale: Before surgery the infant's status is nothing by mouth (NPO), and the infant is stabilized with intravenous fluids and electrolytes. The head of the bed is elevated, and the infant is placed prone to reduce the risk of aspiration. Options 2 and 3 are not accurate during the preoperative period because the infant is kept NPO. An infant is not restrained in a high chair.

A client with acquired immunodeficiency syndrome (AIDS) who has cytomegalovirus retinitis is receiving ganciclovir sodium (Cytovene). The nurse should plan to do which of the following while the client is taking this medication? 1. Monitor blood glucose levels for elevation 2. Administer the medication on an empty stomach only 3. Apply pressure to venipuncture sites for at least 2 minutes 4. Provide the client with a soft toothbrush and an electric razor

4. Provide the client with a soft toothbrush and an electric razor Rationale: Ganciclovir sodium causes neutropenia and thrombocytopenia as the most frequent side effects. For this reason, the nurse monitors the client fro signs and symptoms of bleeding and implements the same precautions that are used for a client receiving anticoagulant therapy. These include providing a soft toothbrush and electric razor to minimize risk of trauma that could result in bleeding. The medication may cause hypoglycemia, but not hyperglycemia. The medication does not have to be taken on an empty stomach. Venipuncture sites should be held for approximately 10 minutes.

A licensed practical nurse (LPN) is reinforcing teaching done by a registered nurse (RN) to parents of a child with celiac disease. The LPN reminds the parents to do which of the following to ensure that the diet is safe based on the child's physical needs? 1. Restrict corn and rice in the diet 2. Serve pasta dishes instead of cereals with grain 3. Keep the intake of fresh starchy vegetables to a minimum 4. Read food labels carefully to avoid hidden sources of gluten

4. Read food labels carefully to avoid hidden sources of gluten Rationale: Gluten is added to many foods such as hydrolyzed vegetable protein derived from cereal grains. Grains are also frequently added to processed foods as thickening or fillers. Because of this, it is important to read food labels. Gluten is found primarily in the grains of wheat and rye. Rice, corn and other vegetables are acceptable in a gluten-free diet. Many pasta products contain gluten and should be avoided.

A nurse notes that a child who has been diagnosed with intussusception has a formed brown bowel movement. The nurse should do which of the following at once to ensure that a safe plan of care is implemented for the child? 1. Prepare the child for hydrostatic reduction 2. Ask the child about any increase in abdominal pain 3. Warn the child and her parents that surgery is imminent 4. Report the passage of the normal stool to the registered nurse (RN)

4. Report the passage of the normal stool to the registered nurse (RN) Rationale: Passage of a formed brown bowel movement usually indicates that an intussusception has reduced itself. The nurse immediately reports this data to the RN, who will in turn report it to the physician. This finding may change the course of the plan of care. Increased abdominal pain is not expected because the child's gastrointestinal tract is more functional. The finding does not indicate the need for immediate surgery.

A nurse employed at a medical unit of a local hospital arrives at work and is told to report (float) to the pediatric unit for the day because there were several pediatric admissions during the night and the pediatric unit needs assistance in caring for the children. The nurse has never worked in the pediatric unit and is anxious about floating to this area. Which of the following is the appropriate nursing action? 1. Call the nursing supervisor 2. Refuse to float to the pediatric unit 3. Ask another nurse to float to the pediatric unit 4. Report to the pediatric unit and identify tasks that can be safely performed

4. Report to the pediatric unit and identify tasks that can be safely performed Rationale: Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally, a nurse cannot refuse to float unless a union contract guarantees that nurses can work only in specified areas or the nurse can prove the lack of knowledge for the performance of assigned tasks. When faced with this event, the nurse should set priorities and identify potential areas of harm to the client. A nurse cannot refuse an assignment and should not ask another to perform an assignment. The supervisor would be called if the nurse is asked to perform a task he or she could not safely perform.

A nurse is assisting in the care of a child who underwent surgical repair of a cleft lip the previous day. The nurse should implement which safe nursing intervention when caring for the surgical incision? 1. Clean the incision only if serous exudate forms 2. Remove the Logan bar carefully to clean the incision 3. Rub the incision gently with a sterile cotton-tipped swab 4. Rinse the incision with sterile water after using diluted hydrogen peroxide

4. Rinse the incision with sterile water after using diluted hydrogen peroxide Rationale: The incision should be rinsed with sterile water when it is cleaned with a solution other than water or saline. The Logan bar is intended to maintain integrity of the suture line; removing the Logan bar on the first postoperative day is incorrect because removal would increase tension on the surgical incision. The incision is cleaned after every feeding and when serous exudate forms. The incision should be dabbed and not rubbed to maintain its integrity.

A licensed practical nurse (LPN) employed in a long-term care facility is observing a nursing assistant ambulating a client with right-sided weakness. The LPN determines that the nursing assistant is performing the procedure safely if the LPN observes the nursing assistant: 1. Standing behind the client 2. Standing in front of the client 3. Standing on the left side of the client 4. Standing on the right side of the client

4. Standing on the right side of the client Rationale: When working with a client, the nurse should stand on the client's affected side. The nurse should position the free hand on the client's shoulder so that the client can be pulled toward the nurse in the event that the client falls forward. The client should be instructed to look up and outward rather than at his or her feet. Options 1, 2 and 3 are incorrect.