Nurs 4 - RN EAQ's - QSEN: Safety

Which priority actions should the nurse implement when providing care to a preschool-age child who presents in the emergency department (ED) after an accidental overdose? Select all that apply. 1 Monitor vital signs 2 Assess mental status 3 Question the parents 4 Initiate CPR, if needed 5 Empty mouth of remnants

1 - Monitor vital signs 2 - Assess mental status 4 - Initiate CPR, if needed The priority nursing actions when providing care to a preschool-age client who presents in the ED after an accident overdose include monitoring vital signs, assessing mental status, and initiating CPR, if needed. Clearing the mouth of remnants and questioning the parents are not the priority actions by the nurse in this situation.

Which nursing action is accurate when terminating exposure for a toddler-age client who presents to the emergency department (ED) after eating a lily? 1 Emptying the mouth 2 Monitoring vital signs 3 Questioning the parents 4 Placing in a side-lying position

1 - Emptying the mouth In order to terminate exposure the nurse would empty the toddler-age client's mouth of any plant remnants. Monitoring vital signs is an assessment action. Questioning the parents helps to identify the poisonous substance. Placing the child in a side-lying position is a nursing action that prevents further absorption or prevents aspiration with emesis.

A nurse is caring for a client in labor whose cervix is dilated 6 cm. The client is receiving epidural analgesia. What common response to regional anesthesia does the nurse anticipate? 1 Urticaria 2 Lightheadedness 3 Elevated temperature 4 Sensation of chilliness

2 - Lightheadedness Lightheadedness may indicate hypotension resulting from the vasodilation commonly associated with epidural analgesia. Urticaria is associated with an allergic response; this is not a common reaction to regional anesthesia. An increase in temperature may be a response to a developing infection or dehydration; these are rare adverse occurrences with regional anesthesia. Feeling chilled is an allergic response, which is not a common reaction to regional anesthesia.

The nurse is caring for a client who survived an earthquake. Which nursing intervention indicates a need for correction? 1 Avoiding stereotypical talk 2 Making prejudicial remarks 3 Maintaining situational awareness 4 Isolating the client in case of airborne disease

2 - Making prejudicial remarks The nurse should avoid prejudicial remarks to develop trust in the client. The nurse should avoid stereotypical talk and should speak calmly. The nurse should maintain situational awareness while caring for clients in emergency department. The nurse should assess the need to isolate the client in case of airborne diseases.

A client presents with a severe stiff neck, shuffling gate, and other extrapyramidal symptoms. Benztropine 2.5 mg by mouth is prescribed. The medication is available in 1-mg scored tablets. How many tablets should the nurse administer? Record your answer using one decimal place. _____ tablet(s)

2.5 tablets

The hepatitis B-positive mother of an infant born earlier in the day wants her infant to receive the hepatitis B immune globulin (HBIG) vaccine. What is the proper dosage of this vaccine? 1 1.0 mL subcutaneously before discharge 2 0.5 mL subcutaneously within 24 hours of birth 3 1.0 mL intramuscularly within 24 hours of birth 4 0.5 mL intramuscularly within 12 hours of birth

4 - 0.5 mL intramuscularly within 12 hours of birth HBIG must be given within 12 hours of birth to be effective. The correct dose is 0.5 mL, and it must be given intramuscularly. The vaccine is not given subcutaneously.

The nurse is transferring a client from the bed to the chair. Which action should the nurse take during the transfer? 1 Place the client in a semi-Fowler position. 2 Stand behind the client during the transfer. 3 Turn the chair so it faces away from the bed. 4 Instruct the client to dangle the legs.

4 - Instruct the client to dangle the legs. The nurse should place the client in high-Fowler position, or 80 to 90 degrees, and then assist the client to the side of the bed. Next, the nurse helps the client sit on the edge of the bed and then instructs the client to dangle the legs. The nurse then faces the client and places the chair next to and facing the head of the bed. The semi-Fowler, or 30 to 45 degrees, position is not high enough to get the client in a sitting position.

3 - Client C Survivors of a major earthquake may develop post-traumatic stress disorder (PTSD). These clients should be assessed using the event scale-revised (IES-R) tool. Based on their scores on the subscales, they are referred to social workers, mental health counselors, psychiatrists, or clinical psychologists. If the score is high on one subscale, as for client C, they are referred to a social worker or mental health counselor. If the scores are high on all subscales, as with client A, they are referred to a psychiatrist or clinical psychologist. As client B has normal scores, he or she would not require any referrals. Client D with a low score on all scales also would not require any referral.

The nurse has evaluated survivors after a major earthquake and referred one of the clients to a social worker for counseling. Which client did the nurse most likely refer to the social worker based on the data in the table? 1 Client A 2 Client B 3 Client C 4 Client D

A nurse is assessing an adolescent after the administration of epinephrine. What side effect is most important for the nurse to identify? 1 Tachycardia 2 Hypoglycemia 3 Constricted pupils 4 Decreased blood pressure

1 - Tachycardia Epinephrine is a sympathetic nervous system stimulant that causes tachycardia. Hyperglycemia, not hypoglycemia, may result. The pupils will be dilated, not constricted. Epinephrine is more likely to cause hypertension than hypotension.

A new father tells a nurse that his sister and her family plan to visit the new baby and that his niece and nephew have just recovered from chickenpox (varicella). Their lesions are completely healed or have scabs and are no longer draining. He asks the nurse whether it is safe for them to be near the baby. What is the best response by the nurse? 1 "The most contagious time is before the spots appear. It'll be safe to visit." 2 "People with open noncontagious lesions shouldn't visit. Tell them to stay home." 3 "People are contagious as long as they still have lesions. Tell them to stay home." 4 "The baby received immunity from the mother at birth. It will be safe for them to visit."

1 - "The most contagious time is before the spots appear. It'll be safe to visit." Chickenpox (varicella) is an infectious respiratory disease spread by droplets; the chief contagious period occurs 1 day before the lesions appear and for 6 days after the first crop of vesicles have crusts. Chickenpox is spread primarily in respiratory droplets, not discharge from the lesions. Not all open lesions are contagious; if prospective visitors know that the lesions are not contagious, they may visit. Passive immunity at birth does not provide complete protection; infants need to be protected against those with active infection.

A client is receiving an antipsychotic medication. When assessing the client for signs and symptoms of pseudoparkinsonism, the nurse will be alert for which complication? 1 Drooling 2 Blurred vision 3 Muscle tremors 4 Photosensitivity

3 - Muscle tremors Drug-induced parkinsonism presents with the classic triad of adaptations associated with Parkinson disease: rigidity, slowed movement (bradykinesia), and tremors. The anticholinergic effects of antipsychotic medication cause dry mouth, not drooling. Neither dry mouth nor drooling is related to pseudoparkinsonism. Blurred vision and photosensitivity are side effects of anticholinergic, not antipsychotic, medications.

A client is to receive 2000 mL of intravenous (IV) fluid in 12 hours. At what rate should the nurse set the electronic infusion control device? Record your answer using a whole number. ______ mL/hr

167 ml/hr

Child maltreatment is suspected in a 3-year-old girl admitted to the hospital with many poorly explained injuries. Which statement by the mother further supports this suspicion? 1 "When I get angry, I take her for a walk." 2 "I have no problems with any of my other children." 3 "When she misbehaves, I send her to her room alone." 4 "I make her stand in the corner when she doesn't eat her dinner."

2 - "I have no problems with any of my other children." Identification of one child in the family as being different by the parents or siblings, coupled with other signs of abuse, should prompt suspicions of physical abuse and warrant further investigation. Taking a walk is helpful for both the mother and the child and does not indicate abuse. Sending a child to his or her room alone is an acceptable punishment for misbehavior. Although making a child stand in the corner is demeaning, it is not physical abuse.

The nurse is conducting triage under mass casualty conditions. Which tag should the nurse use for a client who is experiencing hypovolemic shock due to a penetrating wound? 1 Red 2 Black 3 Green 4 Yellow

1 - Red The nurse would use a red tag for a client who has injuries that are an immediate threat to life, such as hypovolemic shock, during mass casualty conditions. A black tag is used for a client who is expected and allowed to die. A green tag is used for a client with minor injuries that do not require immediate treatment. A yellow tag is used for a client who has major injuries requiring treatment.

Which medical relief team would the nurse expect to help healthcare facilities that face personnel shortages during a mass casualty event? 1 Medical Reserve Corps (MRC) 2 Disaster Medical Assistance Team (DMAT) 3 Hospital Incident Command System (HICS) 4 International Medical Surgical Response Teams (IMSuRTs)

1 - Medical Reserve Corps (MRC) MRC is a group of volunteer medical and public healthcare professionals. MRC helps healthcare settings that face personnel shortages in a mass casualty event. DMAT is a team of civilian medical, paraprofessional, and support personnel that supplies medical equipment to sustain operations for 72 hours. HICS is a facility-level organizational model to standardize disaster operations. IMSuRTs provide fully functional field surgical facilities in a mass casualty event whenever needed.

The home healthcare nurse is evaluating the environments of several preschool-age pediatric clients. Which activities noted during the visits places a child at risk for bodily harm? Select all that apply. 1 The client is swimming in the pool unsupervised. 2 The parents leave medications within reach of the client. 3 A parent tricks the client to eat a vitamin by saying, "This is candy." 4 A parent only allows the client to watch two hours of television each day. 5 The parents ask the client, "Has anyone touched you inappropriately at school?"

1 - The client is swimming in the pool unsupervised. 2 - The parents leave medications within reach of the client. 3 - A parent tricks the client to eat a vitamin by saying, "This is candy." Activities that the nurse notes as potentially harmful include the client swimming unsupervised in the pool, medications that are left within reach of the client, and a parent telling the child that a vitamin is candy. Each of these findings increases the child's risk for bodily harm necessitating the need for intervention. Two hours of television is appropriate for a preschool-age client. A parent question asking the client if he or she has ever been touched inappropriately at school is also appropriate and does not place the child at risk for bodily harm.

A client critically injured in a bomb blast is admitted to an emergency unit. Which order should the nurse follow to perform initial assessment to manage immediate threats in the client? 1. Assessing breathing sounds and respiratory effort 2. Monitoring vital signs 3. Removing all clothing for a complete physical assessment 4. Establishing a patent airway by positioning, suctioning, and oxygen as needed 5. Evaluating the client's level of consciousness using the GCS

1.Establishing a patent airway by positioning, suctioning, and oxygen as needed 2. - breathing sounds and respiratory effort 3. - Monitoring vital signs 4. - Evaluating the client's level of consciousness using the GCS 5. - Removing all clothing for a complete physical assessment The priority intervention in any injured client who survived bomb blast is to establish a patent airway. Establishing a patent airway is done by positioning, suctioning, and administering oxygen as needed. After the patent airway is established, assessing breathing sounds and respiratory effort to determine ventilation is the next priority. When effective ventilation is ensured, the priority shifts to circulation. Circulation is assessed by monitoring vital signs such as blood pressure and heart rate. After assessing circulation, evaluating the client's level of consciousness using the GCS is the next priority. The final component of assessment is removing all clothing for a complete physical assessment.

A client is prescribed sertraline, an antidepressant. What does the nurse include when preparing a teaching plan about the side effects of this drug? 1 Seizures 2 Agitation 3 Tachycardia 4 Agranulocytosis

2 - Agitation Sertraline, a selective serotonin reuptake inhibitor (SSRI), inhibits neuronal uptake of serotonin in the central nervous system, thus potentiating the activity of serotonin. Central nervous system side effects of this drug include agitation, anxiety, confusion, dizziness, drowsiness, and headache. Seizures are a side effect of clozapine, an antipsychotic, not sertraline, which is an antidepressant. Tachycardia is a side effect of tricyclic antidepressants, not sertraline, which is an SSRI antidepressant. A decrease in the production of granulocytes (agranulocytosis) causing a pronounced neutropenia is a side effect of clozapine, not sertraline.

A 2-month-old infant with the diagnosis of heart failure is discharged with a prescription for oral digoxin 0.05 mg every 12 hours. The bottle of digoxin is labeled "0.05 mg/mL." Which item should the nurse teach the mother to use when administering the medication? 1 Nipple 2 Calibrated syringe 3 Plastic measuring spoon 4 Bottle containing an ounce of water

2 - Calibrated syringe A calibrated syringe or dropper provides the most accurate measurement of the medication. Using a nipple or spoon is not an accurate way to measure medication. If the dose of medication is diluted and the infant does not drink the entire ounce, the resulting dose will be insufficient.

Which nursing action is the priority when administering chelation therapy for a preschool-age client? 1 Assessing vital signs 2 Monitoring urine output 3 Conducting a behavioral assessment 4 Providing education to reduce lead exposure

2 - Monitoring urine output Adequate urinary output must be ensured with administration of calcium EDTA, the medication used for chelation therapy. Clients receiving the drug intramuscularly must be able to maintain adequate oral intake of fluids. Monitoring vital signs, conducting a behavioral assessment, and providing education to reduce lead exposure are not priority nursing actions when administering chelation therapy.

The parents of a 6-year-old child with celiac disease tell the school nurse that their child becomes dejected because she is not able to eat snack foods like the rest of her class and friends. What snack can the nurse recommend that is safe for the child to eat? 1 Pretzels 2 Tortilla chips 3 Oatmeal cookies 4 Peanut butter crackers

2 - Tortilla chips Products composed of corn, rice, and millet do not contain gluten and are permitted on a low-gluten diet; tortilla chips are made from corn flour. Pretzels contain wheat flour, which is not permitted on a low-gluten diet; products containing rye, oats, and barley are also restricted. Oatmeal cookies contain oats, which are not permitted on a low-gluten diet. Peanut butter crackers contain wheat flour, which is not permitted on a low-gluten diet.

A 5-year-old-child is undergoing chemotherapy. The mother tells the nurse that the child is not up to date on the required immunizations for school. What is the best response by the nurse? 1 "By this time your child has developed sufficient antibodies to provide immunity." 2 "Maintaining current immunizations is critical. Make sure the series is completed." 3 "This isn't the best time to finish the immunizations, because your child's immune system is suppressed." 4 "It's important to complete the immunizations because your child needs to be protected from childhood diseases that could be fatal."

3 - "This isn't the best time to finish the immunizations, because your child's immune system is suppressed." Chemotherapy compromises the immune system. The vaccines may be administered after the completion of the chemotherapy protocol, once the immune system has returned to its previous state. The child has not developed sufficient antibodies; booster immunizations are needed, but not at this time. Administering immunizations at this time could prove fatal.

An older adult has undergone chemotherapy. Which intervention would be beneficial for the client in preventing the risk of a potentially contagious common viral infection? 1 Administering famciclovir 2 Administering gabapentin 3 Administering the zoster vaccine 4 Administering vaccines for herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2)

3 - Administering the zoster vaccine Herpes zoster or shingles is the most common viral infection that is potentially contagious to anyone who has not had varicella or who is immunosuppressed such as clients on chemotherapy. Incidence increases with age mainly for adults 50 years old or older. Administering the zoster vaccine helps in preventing the risk of shingles. Famciclovir is an antiviral drug that helps in reducing the symptoms of the infection. Gabapentin is prescribed to clients suffering from neuralgia caused by shingles. Vaccines for HSV-1 and HSV-2 are not available.

Which color tag should be given to "walking wounded" clients according to the disaster triage tag system? 1 Red 2 Black 3 Green 4 Yellow

3 - Green Green tagged clients are referred to as "walking wounded" because they may evacuate themselves from the mass casualty scene and go to the hospital in a private vehicle. Clients with life-threatening conditions that need immediate treatment are given red tags. Black-tagged clients are expected to die or may be dead. Clients with major injuries are tagged with yellow. They may require urgent treatment but can wait a short time for care as injuries are not life threatening.

A client demonstrates signs and symptoms of a transfusion reaction. The nurse immediately stops the infusion; what should the nurse's next action be? 1 Obtain blood pressure in both arms. 2 Send a urine specimen to the laboratory. 3 Hang a bag of normal saline with new tubing. 4 Monitor the intake and output every 15 minutes.

3 - Hang a bag of normal saline with new tubing. The tubing must be replaced to avoid infusing the blood left in the original tubing; the normal saline infusion will maintain an open line for any further intravenous (IV) treatment. All vital signs should be taken eventually; blood pressure may be taken on either arm, not necessarily both. A urine sample is collected after the blood transfusion is stopped, the tubing replaced, and a bag of normal saline hung. The specimen will be analyzed to determine kidney function. Although the intake, and especially the output, should be monitored to assess kidney function, this is not the priority.

During a client's paracentesis, 1500 mL of fluid is removed. The nurse monitors the client for which sign of a potentially severe response? 1 Abdominal girth decrease 2 Mucous membranes becoming drier 3 Heart rate increases from 80 to 135 4 Blood pressure rises from 130/70 to 190/80

3 - Heart rate increases from 80 to 135 Fluid may shift from the intravascular space to the abdomen as fluid is removed, leading to hypovolemic shock and compensatory tachycardia. A paracentesis should decrease the degree of distention. Mucous membranes becoming drier is a sign that dehydration may occur, but it is not as vital or immediate as signs of shock. A fluid shift may cause hypovolemia with resulting hypotension, not hypertension.

What are the functions of the Hospital Incident Command System (HICS) in disaster management? Select all that apply. A To manage mass fatalities B To provide first aid stations C To standardize disaster operations D To establish emergency animal care E To establish an emergency operations center (EOC)

C - To standardize disaster operations E - To establish an emergency operations center (EOC) The Hospital Incident Command System (HICS) is the facility-level organizational model for disaster management. It functions to standardize disaster operations. HICS personnel establish an emergency operations center (EOC) or command center. Disaster Mortuary Operational Response Teams (DMORTs) manage mass facilities. A Disaster Medical Assistance Team (DMAT) is a medical relief team that provides first aid stations. A National Veterinary Response Team (NVRT) is a healthcare service that establishes emergency animal care.

A nurse working on a mental health unit is caring for several clients who are at risk for suicide. Which client is at the greatest risk for successful suicide? 1 Young adult who is acutely psychotic 2 Adolescent who was recently sexually abused 3 Older single man just found to have pancreatic cancer 4 Middle-age woman experiencing dysfunctional grieving

3 - Older single man just found to have pancreatic cancer Older single men with chronic health problems are at the highest risk of suicide. This is because men have fewer social supports than women do. (Men are less social then women in general.) Less social support at times of stress can increase the risk of suicide. Also, chronic health problems can lead to learned helplessness, which can lead to depression. People who are acutely psychotic as a group are at higher risk for suicide, but they do not have the suicide rate of older single adult men with chronic health problems. An adolescent who was recently sexually abused, although severely traumatized, does not have the risk of suicide of an older single man with chronic health problems. Dysfunctional grieving is prolonged grieving that is characterized by greater disability and dysfunctional patterns of behavior. Although people with complicated dysfunctional grieving may be at risk for self-directed violence, they do not have the suicide risk of older single men with chronic health problems.

A nurse in a mental health unit of the emergency department of a hospital frequently cares for adolescents who attempt suicide. What is important for the nurse to remember about adolescent suicide behavior? 1 Boys account for more attempts than do girls. 2 Girls use more dramatic methods than do boys. 3 Girls talk more about suicide before attempting it. 4 Boys are more likely to use lethal methods than are girls.

4 - Boys are more likely to use lethal methods than are girls. The finding that boys are more likely to use lethal methods than are girls is supported by research; girls account for 90% of suicide attempts, but boys are three times more successful because of the methods they use. Statistics do not support the assertion that girls talk more about suicide before attempting it than do boys or that girls use more dramatic methods than do boys.

A client paces back and forth across the floor, speaks incoherently, and continually talks to and verbally fights with people who are not present. What is the nurse's initial therapeutic intervention? 1 Setting limits on the client's verbal aggression 2 Isolating the client to decrease the aggressive behavior 3 Establishing a relationship to reduce the client's loneliness 4 Providing emotional support while demonstrating acceptance of the client

4 - Providing emotional support while demonstrating acceptance of the client Clients who have lost contact with reality can be helped to reestablish contact with reality when the nurse demonstrates respect and focuses on the client; this distracts the client's attention from the hallucinations. This client is responding to voices, not reality; setting limits is reality oriented and is usually ineffective unless it involves directing the client to dismiss the voices. The client presents no immediate threat to the self or others; isolating the client will decrease contact with reality and will probably worsen the hallucinations. Although establishing a relationship may lessen the hallucinations, it takes a long time to do so, and the client needs immediate help.