Safety and Psychosocial Development Exam Review (1)

C. brachial

What is the most appropriate location for assessing the pulse of an infant who is less than 1 year old? A. radial B. carotid C. brachial D. popliteal

D. Every 30 minutes

The nurse is caring for a client who has hand restraints. How often should the nurse assess the skin integrity of the restrained hands? A. Every 2 hours B. Every 3 hours C. Every 4 hours D. Every 30 minutes

B. Contact

The nurse should institute which precaution for a client diagnosed with Clostridium difficile? A. droplet B. contact C. airborne D. Neutropenic

A. skin C. inhalation D. gastrointestinal

The community health nurse has completed a teaching session about anthrax with members of the community. The LPN reinforcing the teaching tells those attending that anthrax can be transmitted via which routes? Select all that apply. A. skin B. kissing C. inhalation D. gastrointestinal E. direct contact with an infected individual F. sexual contact with an infected individual

A.aim at the base of the fire

The nurse enteres the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. Which is the next action the nurse should perform? A.aim at the base of the fire B. squeeze the handle on the extinguisher C. sweep the fire from side to side with the extinguisher D. sweep the fire from top to bottom with the extinguisher

C. activate the alarm

The nurse enters the client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. Which is the next nursing action? A. call for help B. extinguish the fire C. activate the alarm D. confine the fire by closing the room door

A. a client on a ventilator

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first? A. a client on a ventilator B. A client in skeletal traction C. A postoperative client preparing for discharge D. A client admitted on the previous shift who has a diagnosis of gastroenteritis

A. wearing gloves when emptying the client's bedpan B. Keeping all linens in the room until the implant is removed C. Wearing a film (dosimeter) badge when in the client's room D. Wearing a lead apron when providing direct care to the client

The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply. A. wearing gloves when emptying the client's bedpan B. Keeping all linens in the room until the implant is removed C. Wearing a film (dosimeter) badge when in the client's room D. Wearing a lead apron when providing direct care to the client E. placing the client in a semiprivate room at the end of the hallway

C. Gloves, gown, and goggles

The nurse is caring for a client with a health-care associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which protective items will be required to perform this procedure? A. Gloves and a gown B. Gloves and goggles C. Gloves, gown, and goggles D. Gloves, gown, and shoe protectors

B. the restraint straps are safely secured to the side rails

The nurse obtains a prescription from the health care provider to restrain a client using a jacket restraint and instructs the UAP to apply the restraint. Which observation, if made by the nurse, should indicate unsafe application of the restraint? A. a safety knot is made in the restraint strap B. the restraint straps are safely secured to the side rails C. the jacket restraint strap does not tighten when force is applied against it D. The jacket restraint is secure, and two fingers can easily slide between the restraint and the client's skin

C. start chest compressions Remember: CAB Compressions, Airway, Breathing

The nurse on the day shift walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. The next nursing action is which? A. deliver breaths B. give the client oxygen C. start chest compressions D. ventilate with a mouth-to-mask device.

C. Jaw thrust maneuver Neck injury is suspected.

The nurse witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway. The nurse opens the airway in this victim with the use of which method? A. Flexed position B. Head tilt-chin lift C. Jaw thrust maneuver D. Modified head tilt-chin lift

C. a UAP who has never had chickenpox

The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster? A. a staff member who has never had roseola B. a staff member who has never had mumps C. a UAP who has never had chickenpox D. a UAP who has never had German Measles

A. "This is a normal behavior at this age." Rationale (because I know ya'll gonna want this one): According to Freud's psychosexual stages of development, the child is in the phallic stage between the ages of 3 and 6 years. At this time, the child devotes much energy to examining his or her genitalia, masturbating, and expressing interest in sexual concerns.

The parents of a 4 year old child tell the nurse that they are concerned because the child has been masturbating. Which is the appropriate response by the nurse? A. "This is a normal behavior at this age." B. "Children usually begin this behavior at the age of 8 years." C. "This is not normal behavior. The child should be brought to the mental health clinic." D. "The child is very young to begin this behavior and should be brought to the mental health clinic."

C. Call the poison control center

A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first? A. Induce Vomiting B. Call an ambulance C. Call the poison control center D. Bring the child to the ER

B. A client who requires frequent ambulation

The nurse is planning client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel? A. A client who requires wound irrigation B. A client who requires frequent ambulation C. A client who is receiving continuous tube feedings D. A client who requires frequent vital signs after a cardiac catheterization

A. Logrolling

The nurse is turning a postoperative client who had extensive spinal surgery on the previous day. Which turning intervention or position would be best for repositioning this client? A. Logrolling B. Semi-Fowler's C. Sims' D. 30-degree lateral (side-lying)

A. find someone who can help

The nurse is preparing to reposition a dependent client who weighs more than 250 lbs. Which intervention is best for teh nurse to consider when moving this client? A. find someone who can help B. place the client in Trendelenburg's position C. keep elbows close and work close to the body. D. administer oral pain medication 5 minutes before moving the client

A. Allow the infant to signal a need

The nurse is providing instructions to a new parent regarding the psychosocial development of the infant. Using Erikson's psychosocial develpment theory, which instruction should the nurse reinforce to the parents? A. Allow the infant to signal a need B. Anticipate all of the needs of the infant C. Attend to the crying infant immediately D. Avoid the infant during the first 10 minutes of crying

A. as-needed meds given that shift

The nurse is recording an end of shift report for a client. Which information needs to be included? A. as-needed meds given that shift B. normal vital signs that have been normal since admission C. all of the tests and treatments the client has had since admission D. total number of scheduled meds that the client received on that shift

C. "At this age, the child is developing his or her own personality." Erikson, ages 7-12

The parents of an 8 year old child tell the nurse that they are concerned about the child because the child seems to be more attentive to friends than anyone else. Which is the appropriate nursing response? A. "You need to be concerned." B. You need to monitor the child's behavior closely." C. "At this age, the child is developing his or her own personality." D. "You need to praise the child more often to stop this behavior."

C. wear a gown and gloves

The nurse is told that an assigned client is suspected of having MRSA. Which precautions should the nurse institute during the care of the client? A. wear gloves only B. wear a mask and gloves C. wear a gown and gloves D. avoid touching the client's clothes