PassPoint - Safety

The client is diagnosed with a detached retina in the right eye. What should the nurse do first?

Promote measures that limit mobility. Promoting measures that limit mobility may prevent further injury. Following surgical repair of a detached retina, cool or warm compresses are applied to edematous eyelids, if prescribed. The client should avoid lying face down, stooping, or bending preoperatively. It is not necessary to remove all pillows.

The perioperative nurse is participating in open reduction and internal fixation (ORIF) of a client's femoral fracture when a fire breaks out near the anesthesia station. Place the actions involved in implementing the RACE steps of fire response into the correct sequence. All options must be used.

Promptly wheel the client out of the operating room. Activate the fire alarm system. Enclose the fire to limit spread. Attempt to put out the fire, if it is safe to do so.

A client says to the nurse, "My intravenous line hurts." The nurse assesses the client's peripheral intravenous line and suspects phlebitis. What assessment data confirm the nurse's suspicion? Select all that apply.

Redness, warmth, pain, and edema are all signs and symptoms of phlebitis. Respiratory distress is a sign of an air embolus.

A nurse is teaching the proper use of crutches to a school-age child with a femur fracture with no weight bearing. What will the nurse include with teaching about walking with crutches?

"After advancing both crutches the length of one step, move your 'good' leg forward."

A nurse is conducting a teaching session with a group of parents on infant care and safety to assist parents in appropriately preparing to take their neonates home. Which statement about automobile restraints made by one of the parents would indicate to the nurse that learning has taken place?

"Infants should ride in a rear-facing car seat until they have reached the maximum weight allowed by the car seat manufacturer or are 2 years old."

Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education?

"The client is receiving physical therapy twice per day, so they don't need a continuous passive motion device." Further staff education is needed when the nurse states that the continuous passive motion device isn't needed because the client receives physical therapy twice per day. The continuous passive motion device should be used in conjunction with physical therapy because the device helps prevent adhesions. Bleeding is a complication associated with the continuous passive motion device; skin integrity should be monitored while the device is in use.

A nurse is verifying a medication calculation completed by a nursing student prior to administration. The adult client is to receive ampicillin 150 mg/kg/day I.V. divided in 6 even doses with a maximum dose of 12 g/day. The client's weight is 80 kg. How many mg/dose will the client receive? Record your answer using whole number.

The nurse should verify that the total dosage will not exceed the maximum dosage of 12 g/day. 150 mg/kg / day x 80 kg = 12,000 mg/day ÷ 6 doses = 2,000 mg per dose

A nurse prepares to transfer a client from a bed to a chair. Which principle demonstrates safe body mechanics?

The nurse uses a rocking motion while helping the client to stand. Rocking provides extra force when pushing or pulling. The nurse should keep any weight as close to the nurse's body as possible when lifting — not at arm's length. The nurse should keep knees slightly bent and feet spread apart to provide a wide base of support. Keeping the knees straight and stiff and bending at the waist and keeping the feet close together aren't examples of safe body mechanics. These positions could result in injury to the nurse or to the client.

A nurse is caring for a client who is disoriented to time, place, and person and is attempting to get out of bed and pull out an intravenous line. The nurse receives orders from a health care provider to apply a vest restraint and bilateral soft wrist restraints. In carrying out this order, which nursing actions would be appropriate? Select all that apply.

Tie the restraints in quick-release knots. Document the client's condition. Document alternative methods used before the restraints were applied

Which clients will the nurse place in reverse isolation? Select all that apply.

client with a white blood cell count (WBC) of 600 µL with a granulocyte count of 100 µL client with a burn injury involving > 30% of the total body surface area (TBSA) Reverse or protective isolation is used for clients with diseases and conditions in which there is increased susceptibility to infection such as clients with neutropenia, clients receiving chemotherapy, severely immunocompromised clients, and burn clients. Client isolation techniques attempt to break the chain of infection by interfering with transmission.

A client is being treated with internal radium implants. The nurse should assess the client for which adverse effect associated with radiation therapy to the cervix?

nausea and a foul vaginal discharge Nausea, vomiting, and a foul vaginal discharge are common adverse effects of internal radiation therapy for cervical cancer. A foul-smelling discharge may develop from the destruction and sloughing of cells. Vaginal discharge may persist for some time. General signs and symptoms of radiation syndrome include nausea, vomiting, anorexia, and malaise. Vaginal itching, confusion, and high fever are not typical adverse effects of radiation therapy for cervical cancer.

The nurse is discharging a newborn with clubfoot who has had a cast applied. The nurse should provide additional teaching to the parents if they make which statement?

"I should use a pillow to elevate my child's foot as they sleep." Elevating the extremity at different points during the day is helpful to prevent edema, but pillows should not be used in the crib because they increase the risk for sudden unexplained infant death syndrome (SUIDS). A change in the color of the toes is a sign of impaired circulation and requires medical evaluation. Children typically need a series of 5 to 10 casts to correct the deformity. Infants with clubfeet still need frequent holding like any other newborn.

The nurse is verifying the identity of a client prior to administering medication. The client has had a stroke and has ataxia. What is the best action by the nurse?

Ask the client to state name and birthdate.

A nurse and a nursing student drive to the home of a client with postpartum depression and discover the client and her baby completely naked in the backyard. The client is unable to communicate in an effective manner. What is the nurse's most appropriate response to resolve this situation?

Contact the nursing supervisor to clarify the appropriate actions in this acute mental health situation.

A nurse notes that another nurse on the previous shift made an entry on the wrong client's health record. What are the most appropriate steps for the first nurse to take?

Contact the previous nurse requesting that the nurse correct the error.

A 17-year-old female client with severe nodular acne is considering treatment with isotretinoin. What does the nurse instruct the client to do prior to beginning the medication?

Enroll in a risk management plan. Because of the risk for birth defects with isotretinoin, risk management plans require all clients to meet certain requirements to obtain the medication. Providers are advised to closely monitor clients for signs of depression, but a mental health evaluation is not universally required. It is not sufficient to begin a single form of an effective method of birth control with the first dose of the medication. Women of childbearing age must use two forms of effective birth control for 1 month before, during, and 1 month after taking the drug. Isotretinoin may cause muscle aches, and extreme exercise should be avoided, but general participation in sports should be considered on an individual basis.

The nurse working in the intensive care unit notices that a nurse colleague on the unit is giving clients sedation without a health care provider's prescription. What should the nurse do first?

If a nurse colleague is exhibiting an unsafe practice, the first step is to express concern to that colleague to try to prevent client harm. After expressing concern to the nurse colleague, the nurse should also report the behavior as appropriate through an occurrence report or directly to the supervisor. Additionally, it may be necessary to notify the nursing licensing organization or compliance hotline if the immediate supervisor does not take action to address the behavior.

A client is admitted to the hospital for an asthma exacerbation. The nursing history reveals this client was exposed to varicella (chickenpox) 1 week ago. When, if at all, would this client require isolation?

Immediate isolation in a private room is required . The incubation period for varicella (chickenpox) is 2 to 3 weeks, usually 13 to 17 days. A client is commonly isolated 1 week after exposure to avoid the risk of a breakout. A person is infectious from 1 day before eruption of lesions to 6 days after the vesicles have formed crusts.

A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated?

Immunoglobulin E (IgE) is involved with an allergic reaction. IgA combines with antigens and activates the complement system. IgB coats the surface of B lymphocytes. IgG is the principal immunoglobulin formed in response to most infectious agents.

Nearly 20 people have presented and been brought to the emergency department (ED) after a truck crashed into a crowd of people. When the nurse is triaging clients, it is most appropriate for the nurse to take what initial action?

In a mass casualty situation, the nurse may be required to perform an across-the-room visual assessment to identify clients in the most acute distress. Assessing clients in the sequence they came or by their age has the potential to ignore acuity. Similarly, clients who present by EMS are not necessarily in greater distress than clients brought to the ED by other means.

The nurse was caring for a client who died from blood loss following the birth of their child. The death was not expected as the client did not have any medical conditions. Which initial action is most appropriate for the nurse manager to implement?

Initiate a root cause analysis on the event.

When the nurse is removing personal protective covering, what action should this nurse (see figure) take to avoid spreading nosocomial infections?

Remove the face mask.

A nurse in a psychiatric care unit finds that a client with psychosis has become violent and has struck another client in the unit. What action should the nurse take in this case?

Restrain the client, as they are harmful to the other clients.

The school nurse learns that at least one of the children in the school has a new diagnosis of erythema infectiosum (human parvovirus) after developing a bright red facial rash. What interventions should be implemented to prevent a possible spread of the infection to other students in the school?

Teach everyone to implement hand hygiene. Erythema infectiosum (human parvovirus) is transmitted through direct contact with respiratory secretions. The client is contagious for a week prior to the appearance of the rash, but not after the rash appears, so quarantine of the diagnosed client will not reduce transmission. However, other children may already have been infected and hand hygiene can reduce the spread of the infection. Human parvovirus is not transmitted by animals. Administering a pain reliever to the client will not reduce the risk of infection to others.

The nurse is to apply a sequential compression device (intermittent pneumatic compression). Identify the area of the compression device that is placed on the client's calf.

The air cell should be centered on the back of the client's calf.

A client who was discharged earlier in the day returns to the nursing unit and demands acetaminophen with codeine. The client is advised that the client is no longer being treated on the unit and this medication cannot be administered. The client states, "I know where you park your cars, and you'd better watch out when you leave here tonight." What is the next step that the nurse should take?

The nurse should call the police because threatening staff is a criminal act. Nursing supervisors are not able to take the same actions as police officers to protect the staff. Asking to meet with the client privately is unsafe; the client's behavior is unpredictable, and the client could be a risk to others or self. Calling the client's family is not appropriate given the threats uttered.

The pediatric nurse is providing care for an infant who has been diagnosed with respiratory syncytial virus (RSV). What action best prevents the spread of this infectious microorganism?

Wear a face mask and shield when in close contact with the client. RSV infection necessitates droplet precautions, including the use of a facemask and shield. Goggles are not normally included in droplet precautions. It is important to educate family members and visitors about the need for hand hygiene, but the similarities and differences between the two different methods of performing hand hygiene are not a priority. Antiviral medications such as ribavirin are not commonly used, and they do not directly prevent the spread of the infection.

A client with cervical cancer is undergoing internal radium implant therapy. A lead-lined container and a pair of long forceps have been placed in the client's hospital room. What should the nurse tell the client about how these will be used? The forceps and container will be used for:

handling of the dislodged radiation source

After striking their head on a tree while falling from a ladder, a client is admitted to the emergency department. The client is unconscious and their pupils are nonreactive. Which intervention should the nurse question?

performing a lumbar puncture The client's history and assessment suggest that they may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done because it can quickly decompress the central nervous system, causing additional damage. After a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce ICP.

An adolescent client who is being seen by the crisis nurse after making several superficial cuts on their wrist states that all their friends are siding with their ex-partner and will not talk to the client anymore. The client says that although they know the relationship is over, "If I can't have my ex, no one else will." Which client problem takes the highest priority?

risk for other-directed violence The threat toward the ex-partner is the most immediate concern now, as the client turns their anger toward their ex-partner instead of themself. Although situational low self-esteem, risk for suicide, and risk-prone health behavior are evident, these problems are less of a concern at this time.

A client with obsessive-compulsive disorder must brush the hair back from the forehead 15 times before performing any other activity. The nurse notices that the client's hair is thinning and that the skin on the forehead is irritated. What is the nurse's highest priority in planning care for this client?

setting consistent limits on the ritualistic behavior if it harms the client or others

A client moves in with their family after their roommate of 4 weeks told the client to leave. The client is admitted to the subacute unit after reporting feeling empty and lonely, being unable to sleep, and eating very little for the last week. The client's arms are scarred from frequent self-mutilation. What should the nurse do in order of priority from first to last? All options must be used.

Monitor for suicide and self-mutilation. Monitor sleeping and eating behaviors. Discuss the issues of loneliness and emptiness. Discuss options for housing after discharge.

The nurse is preparing to suction a tracheostomy for a client with methicillin-resistant Staphylococcus aureus (MRSA) (see figure). What should the nurse do next?

The nurse is wearing protective personnel equipment appropriate for suctioning the client: goggles, gown, and respirator mask. It is not necessary to wear a PAPR face shield to suction a tracheostomy. A surgical mask does not provide maximum protection. The nurse must wear protective personnel equipment when caring for a client with a MRSA infection.

A nurse realizes she is 1 hour and 30 minutes late in administering a dose of medication for a 4-year-old child. She gives the medication immediately, and assesses the child. The child isn't harmed by the delay. Which action should the nurse take next?

The nurse should follow facility procedures for reporting an error.

The pediatric nurse is providing care for an infant who has been diagnosed with respiratory syncytial virus (RSV). What action best prevents the spread of this infectious microorganism?

Wear a face mask and shield when in close contact with the client