Safety Silvestri exam
The nurse is assessing the extremities of a client who had wrist restraints applied 2 hours ago. Which findings noted by the nurse are indicative of impaired circulation? Select all that apply. 1.Areas of pallor 2.Areas of erythema 3.Decreased movement 4.Heightened sensation 5.Decreased temperature 6.Reports of pain or tingling
- Areas of pallor - Decreased movement -Decreased temperature
A client is being discharged to home after application of a plaster leg cast. Which statement indicates to the nurse that the teaching has been effective? 1."I will avoid getting the cast wet." 2."I will use my fingertips to lift and move the leg." 3."I can use a padded coat hanger end to scratch under the cast." 4."I need to cover the casted leg with warm blankets for the next few days."
" I will avoid getting the cast wet"
The nurse provides home care instructions to a client with sickle cell anemia. Which statement by the client indicates a need for further instruction? 1."I'm going to take a painting class." 2."I've learned to knit and sew my own clothes." 3."When I'm feeling better, I'm returning to the soccer team." 4."I'm using a schedule to maintain my increased fluid intake."
"When I'm feeling better, I'm returning to the soccer team"
A nursing student is assigned to administer an intramuscular iron injection to a client. The coassigned nurse asks the student about the technique for administration of this medication. The student indicates understanding of the administration procedure by identifying what as the correct injection site and method?
Ventrogluteal muscle using Z-track technique
The nurse is administering an acetaminophen suppository to a child with a fever. The nurse inserts the suppository into the rectum a distance of no more than how many centimeters? 1.0.5 2.1 3.2 4.2.5
2
The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention if noted in the plan indicates the need for revision of the plan? 1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a lead apron when providing direct care to the client 4. Placing the client in a semiprivate room at the end of the hallway.
4.A private room with a private bath is essential if a client has an internal radiation implant.
The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? 1.Call for help. 2.Extinguish the fire. 3.Activate the fire alarm. 4.Confine the fire by closing the room door.
Activate the fire alarm
The nurse is assigned to care for a client experiencing episodes of postural hypotension. Which action should the nurse take to ensure safety while transferring the client from the bed to the chair?
Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.
The nurse is assigned to care for a client who is experiencing episodes of postural hypotension. Which action should the nurse take to ensure safety while transferring the client from the bed to the chair? 1.Arrange for a transfer board to be used. 2.Perform the transfer using a hydraulic lift only. 3.Put the client's shoes on so that the client will not slip on the floor during the transfer. 4.Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.
Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.
The nurse is preparing to administer an intramuscular (IM) injection to a client receiving a continuous heparin infusion. Which action should the nurse prepare to do? 1. Use a ⅝-inch needle for the injection. 2.Apply prolonged pressure to the IM site after the injection. 3.Apply a 4 × 4 pressure dressing at the IM site after the injection. 4.Decrease the rate of the heparin infusion for 1 hour before and 1 hour after the injection.
Apply prolonged pressure to the IM site after the injection.
The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? 1.Out-of-bed activities as desired 2.Bed rest with the affected extremity kept flat 3.Bed rest with elevation of the affected extremity 4.Bed rest with the affected extremity in a dependent position
Bed rest with elevation of the affected extremity
An adolescent is admitted to the hospital after an accidental self-inflicted gunshot wound to the foot. The nurse should plan to take which action as a first step for the prevention of future injury? 1.Explore the client's knowledge of gun safety. 2.Assess the client for a history of risk-taking behaviors. 3.Refer the client to a firearm safety class sponsored by the hospital. 4.Have the client watch a video on the tragedies of improper firearm use.
Explore the client's knowledge of gun safety
The nurse is preparing discharge resources for a client being discharged to the homeless shelter. When looking at the discharge medication reconciliation form, the nurse determines there is a need for follow-up if which medication was prescribed? 1.Glipizide 2.Lisinopril 3.Metformin 4.Beclomethasone
Glipizide
The nurse is preparing to apply a mitten restraint to the client's hand. The nurse should take which action to ensure that the restraint is applied correctly? Click on the Question Video button to view a video showing preparation procedures. 1.Applies the restraint loosely 2.Makes sure that 2 fingers can be inserted under the restraint 3.Secures the restraint straps to the side rail using a quick-release tie 4.Makes sure that the sheepskin is on the outside rather than against the client's skin
Make sure that 2 fingers can be inserted under the restraint
When administering an intramuscular injection in the ventrogluteal muscle, how should the nurse position the client to best relax the muscle? 1.Semi-Fowler's position 2.Prone with a toe-in position 3.On the side with the hip and knee of the uppermost leg flexed 4.On the side with the hip and knee of the lowermost leg flexed
On the side with the hip and knee of the uppermost leg flexed
The nurse is caring for a client with impaired mobility that occurred as a result of a stroke. The client has right-sided arm and leg weakness. Which assistive device should the nurse suggest that the client use to provide the best stability for ambulating? 1.Walker 2.Crutches 3.Quad cane 4.Single straight-legged cane
Quad cane
The nurse is providing instructions to the assistive personnel (AP) who will be caring for a client with hand restraints. The nurse asks the AP to repeat the instructions to ensure that the AP understands the care. Which statement, if made by the AP, indicates an understanding of the care for this client? 1. "I need to remove the restraints every 4 hours." 2. "I need to make sure that the restraints are securely tied to the side rails." 3. "If the family comes in to visit, I can tell them to take the restraints off if they want to." 4. "I need to remove the restraints at least every 2 hours to perform range-of-motion exercises."
"I need to remove the restraints at least every 2 hours to perform range-of-motion exercises"
The nurse checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take? 1. Hold the feeding and reinstill the residual amount. 2. Reinstill the amount and continue with administering the feeding. 3. Elevate the client's head at least 45 degrees and administer the feeding. 4. Discard the residual amount and proceed with administering the feeding.
1 Rationale: Unless specifically indicated, residual amounts greater than 100 mL require holding the feeding, but this is individualized and each agency's policy should be checked. The residual amount should be reinstilled unless it is greater than 250 mL or per agency policy. In addition, the feeding is not discarded unless its contents are abnormal in color or characteristics.
The nurse is caring for an older client who had a hip pinned after being fractured. Which should the nurse do to prevent further injury? 1.Respond to the call light within 10 minutes. 2.Use a night-light in the hospital room and the bathroom. 3.Medicate the client with a sleeping pill to encourage him or her to sleep through the night. 4.Keep all 4 side rails in the up position, preventing the client from getting out of bed.
2. Use a night-light in the hospital room and the bathroom
The nurse working in the hospital hears a client call out that there is a fire in the hospital room. What actions should the nurse take? Arrange the actions in the order that they should be performed. All options must be used. Select the correct sequence number for each item. 1.Extinguish the fire. 2.Activate the fire alarm. 3.Protect the client from injury. 4.Pull the pin on the fire extinguisher. 5.Close the doors to the other clients' rooms.
3. Protect the client from injury 2. Activate the fire alarm 5. Close the doors to the other clients' rooms 4. Pull the pin on the fire extinguisher 1. Extinguish the fire
The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted? 1.A clotting time of 10 minutes 2.An ammonia level of 10 mcg/dL (6 mcmol/L). 3.A platelet count of 50,000 mm3 (50 × 109/L) 4.A white blood cell count of 5000 mm3 (5.0 × 109/L)
A platelet count of 50,000 mm^3 (50x10^9/L) Rationale:Bleeding precautions need to be initiated when the platelet count decreases. The normal platelet count is 150,000 to 450,000 mm^3 (150-400x^9/L). When the platelet count decreases, the client is at risk for bleeding. The normal white blood cell count is 5000 to 10,000 mm^3 (5.0-10.0x10^9/L). When the white blood cell count drops, neutropenic precautions need to be implemented. The normal clotting time is 8-15 minute. The normal ammonia value is 10 to 80 mcg/dL (6-47 mcmol/L).
A nursing student is caring for a client with a stroke (brain attack) who is experiencing unilateral neglect. The nurse would intervene if the student plans to use which strategy to help the client adapt to this deficit? 1.Telling the client to scan the environment 2.Placing the bedside articles on the affected side 3.Approaching the client from the unaffected side 4.Moving the commode and chair to the affected side
Approaching the client from the unaffected side
The nurse is caring for a client who is scheduled for abdominal surgery and administers the preoperative medications as prescribed. The nurse then raises the side rails on the stretcher, places the safety strap across the client, places the call bell near the client, and instructs the client to call for assistance as needed. Shortly thereafter the client calls the nurse and reports the need to urinate. Which action should the nurse take to meet this client's need? 1.Assist the client onto a bedpan. 2.Assist the client to the bathroom. 3.Contact the primary health care provider and request a prescription for a Foley catheter. 4.Tell the client that preoperative medications cause the urge to void, and check the bladder for distention.
Assist the client onto a bedpan
While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which INITIAL action? A. Call the HCP B. Reinsert he implant into the vagina C. Pick up the implant with gloved hands and flush it down the toilet D. Pick up the implant with long-handled forceps and place it in a lead container
D. Pick up the implant with long-handled forceps and place it in a lead container
A client is receiving outpatient radiation treatments for carcinoma of the oropharynx and is experiencing dysphagia. The nurse should include which intervention in the plan of care? 1.Encourage the client to drink only thin liquids. 2.Teach the client to examine his oral mucosa monthly. 3.Teach the client to speak slowly and enunciate clearly. 4.Encourage the client to use artificial saliva to manage dryness.
Encourage the client to use artificial saliva to manage dryness.
The nurse is caring for a client who is on strict bed rest. The nurse develops a plan of care and develops goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is appropriate to prevent these disorders from developing? 1.Restricting fluids 2.Placing a pillow under the knees 3.Encouraging active range-of-motion exercises 4.Applying a heating pad to the lower extremities
Encouraging active range-of-motion exercises
The nurse is developing a plan of care for a client with a diagnosis of early-stage Alzheimer's disease. The plan of care should include nursing interventions that address which early characteristic of Alzheimer's disease? 1.Confusion is common. 2.The client may wander. 3.The client may be easily frustrated. 4.Forgetfulness interferes with the daily routine.
Forgetfulness interferes with the daily routine
The nurse is inserting an indwelling urinary catheter into a client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. What action should the nurse take next? 1.Immediately inflate the balloon. 2.Insert the catheter 2.5 to 5 cm and inflate the balloon. 3.Withdraw the catheter about 1 inch and inflate the balloon. 4.Insert the catheter until resistance is met and inflate the balloon.
Insert the catheter 2.5 to 5 cm and inflate the balloon.
The nurse is preparing to feed a client who is at risk for aspiration. The nurse assesses the client and uses a penlight and tongue blade to check the mouth and cheeks for pockets of food. Which action does the nurse take next? Click on the Question Video button to view a video showing preparation procedures. 1.Obtains a baseline Spo2 reading 2.Adds thickener to the food 3.Places the client in a Fowler's position 4.Asks the client to swallow while palpating the throat
Places the client in a Fowler's position
The nurse has called a client's primary health care provider (HCP) to clarify a medication prescription. The HCP gives a telephone prescription to the nurse for a new medication. What action by the nurse would best promote accuracy at this time? 1. Ensure that the prescription is written neatly. 2.Double-check the prescription with another registered nurse. 3.Call the pharmacy to verify the accuracy of the prescribed medication. 4.Read the prescription back to the PHCP after writing it on the prescription sheet.
Read the prescription back to the HCP after writing it on the prescription sheet.
The nurse is planning to instruct a client with chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Which instruction should the nurse plan to include in the client's teaching plan? 1.Turn the head slowly when spoken to. 2.Remove throw rugs and clutter in the home. 3.Go to the bedroom and lie down when vertigo is experienced. 4.Drive only when feelings of dizziness have not been experienced for several hours.
Remove throw rugs and clutter in the home.
The nurse is preparing a plan of care for a postpartum client who is at risk for postpartum endometritis. Which intervention should the nurse include in the plan of care to minimize this risk? 1.Encourage early ambulation. 2.Discuss the resumption of home care and other activities with the client. 3.Review hand-washing techniques and pericare procedures with the client. 4.Instruct the client in proper positioning of the newborn to facilitate breast-feeding.
Review hand-washing techniques and pericare procedures with the client.
The nurse is providing mouth care to an unconscious client. The nurse should avoid which action during this procedure? 1.Turning the head to 1 side 2.Using oral suction equipment 3.Rinsing with a large volume of fluid 4.Using a bite stick or padded tongue blade
Rinsing with a large volume of fluid
The nurse is caring for an 18-month-old child who has been vomiting. Which is the most appropriate position for this child while sleeping? 1.Supine 2.Side-lying position 3.Prone with the head elevated 4.Prone with the face turned to the side
Side-lying position
The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy? 1. Restrict all visitors. 2. Restrict fluid intake. 3. Teach the client and family about the need for hand hygiene. 4. Insert an indwelling urinary catheter to prevent skin breakdown
Teach the client and family about the need for hand hygiene
The home care nurse visits a client at home who has been experiencing increased weakness. The client tells the nurse that he is using a cane that was purchased at a local pharmacy. The home care nurse assesses the client's use of the cane and determines that the cane is sized correctly if which observation is made? 1.The handle of the cane is even with the client's waist. 2.The client's elbow is straight when ambulating with the cane. 3.The client's elbow is flexed at a 15- to 30-degree angle when ambulating with the cane. 4.The client's elbow is flexed at a 50- to 75-degree angle when ambulating with the cane.
The client's elbow is flexed at a 15- to 30-degree angle when ambulating with the cane.
The home care nurse is performing an environmental assessment in the home of an older client. Which observation by the nurse requires intervention? 1. Unsecured scatter rugs 2.Clear exit passageways 3.An operable smoke detector 4.A prefilled medication cassette
Unsecured scatter rugs
The nursing student develops a plan of care for a client with paraplegia who is at risk for injury related to spasticity of the leg muscles. On reviewing the plan, the coassigned licensed nurse identifies which action as an incorrect intervention? 1.Using prescribed muscle relaxants as needed 2.Using padded restraints to immobilize the limb 3.Performing range-of-motion exercises to the affected limbs 4.Removing potentially harmful objects near the spastic limbs
Using padded restraints to immobilize the limb
The nurse prepares a client for ear irrigation as prescribed by the primary health care provider. Which action should the nurse take when performing the procedure? 1.Warm the irrigating solution to 98.6° F (37.0° C). 2.Position the client with the affected side up following the irrigation. 3.Direct a slow, steady stream of irrigation solution toward the eardrum. 4.Assist the client to turn her or his head so that the ear to be irrigated is facing upward.
Warm the irrigating solution to 98.6 F (37.0 C)
A client has a cerebellar lesion. The nurse would plan to obtain which item for use by this client?
walker Rationale: The cerebellum is responsible for balance and coordination. A walker provides stability for the client during ambulation. A raised toilet seat is useful if the client has sufficient mobility or ability to flex the hips. A slider board is used in transferring a client with weak or paralyzed legs from a bed to stretcher or wheelchair. Adaptive eating utensils are beneficial if the client has partial paralysis of the hand.
The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse should implement which action next? 1.Reassess the client. 2.Conduct a staff meeting to describe the fall. 3.Contact the nursing supervisor to update information regarding the fall. 4.Document in the nurse's notes that an occurrence report was completed.
Contact the nursing supervisor to update information regarding the fall
The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first? 1.Check for medication interactions. 2.Determine whether there are medication duplications. 3.Determine whether a family member supervises medication administration. 4.Call the prescribing primary health care provider (PHCP) and report polypharmacy.
Determine whether there are medication duplications
The nurse is providing instructions to a client regarding the use of a walker. Which statement by the client would indicate the need for further instruction? 1."I need to inspect the rubber tips daily." 2."I need to wear shoes when ambulating." 3."I need to pick up the walker and move it forward, and then walk into the walker, 1 step at a time." 4."The walker height should allow for about 45 degrees of flexion at my elbow so that the height of the walker will be safe."
"The walker height should allow for about 45 degrees of flexion at my elbow so that the height of the walker will be safe."
The nurse is completing medication reconciliation with a client just before discharge to home. The client asks, "Why are you going over this list? They did that when I was admitted!" Which statement by the nurse is the best response? 1."Medication reconciliation is required before you can go home." 2."Your insurance company requires a list of medications that you will be taking." 3."We are checking to see what medications can be discontinued before you go home." 4."We do this to make sure you will be receiving the correct medications once you are at home."
"We do this to make sure you will be receiving the correct medications once you are at home."
The nurse is assessing an older adult who was just admitted to the emergency department with a possible hip fracture. What typical complaints of types and/or locations of pain might the nurse expect? Select all that apply. 1.No pain 2.Groin pain 3.Sciatic pain 4.Pain referred to the lower leg 5.Pain referred to the lower back 6.Pain referred to the back of the knee
1. No pain 2. Groin pain 5. Pain referred to the lower back 6. Pain referred to the back of the knee
The nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the nurse inflates the balloon, the client complains of discomfort. The nurse should take which appropriate action? 1.Aspirate the fluid, remove the catheter, and insert a new catheter. 2.Aspirate the fluid, advance the catheter farther, and reinflate the balloon. 3.Remove the syringe from the balloon; discomfort is normal and temporary. 4.Aspirate the fluid, withdraw the catheter slightly, and reinflate the balloon.
Aspirate the fluid, advance the catheter farther, and reinflate the balloon.
The nurse is preparing the morning medications to be administered to assigned clients and is reviewing the primary health care provider's prescriptions. Which medication prescription should the nurse question? 1.Lanoxin 0.25 mg orally daily 2.Hydrochlorothiazide orally twice daily 3.Docusate sodium 100 mg orally twice daily 4.Enoxaparin sodium 20 mg subcutaneously daily
Hydrochlorothiazide orally twice daily
A client who is receiving therapy with a hypothermia blanket starts to shiver. The nurse raises the blanket temperature and monitors the client. After 15 minutes the client's temperature has not increased and the client is still shivering. What should the nurse do next? 1. Apply a smaller heating pad to the client's axillae and neck areas. 2. Wait 10 more minutes and then check the client's temperature again. 3. Remove the hypothermia blanket and notify the client's health care provider (HCP). 4. Increase the blanket's temperature again and recheck the client's temperature in 15 minutes.
Remove the hypothermia blanket and notify the client's primary health care provider.
The nurse has observed that an older client has episodes of extreme agitation. Which measure is most appropriate for the nurse to implement to avoid episodes of agitation? 1.Wait until the client's agitation has subsided before approaching the client. 2.Speak and move slowly toward the client while assessing the client's needs. 3.Speak to the client at the entrance of the room to avoid any episodes of agitation. 4.Walk up behind the client and gently put a hand on the client's shoulder while speaking.
Speak and move slowly toward the client while assessing the client's needs
The nurse is preparing to initiate an intravenous (IV) puncture on a client and obtains the prescribed solution of 1000 mL of normal saline for the infusion. The nurse sets up the IV infusion and checks which before performing the venipuncture? 1.The client's temperature 2.The client's blood pressure 3.The client's electrolyte values 4.The IV solution for particles or contamination
The IV solution for particles or contamination
The nurse is caring for an older client with dysphagia who is at risk for aspiration. When preparing the client for eating, the nurse should place the client in which position to minimize the risk for aspiration? 1.Low-Fowler's 2.On the left side 3.Upright in a chair 4.On the right side
Upright in a chair
A client with right leg hemiplegia has a problem with mobility. The nurse determines a need for reinforcement of teaching the client and the client's family if the nurse observes which action being done by the family?1.Applying a premolded splint 2.Active range of motion to the affected leg 3.Passive range of motion to the affected leg 4.Encouraging the client to stand unassisted on the leg
4.Encouraging the client to stand unassisted on the leg Rationale: Depending on the client's functional ability, either passive or active range of motion is indicated to keep the joint moving freely. Application of a premolded splint also would keep the limb aligned and in good position. The client should not attempt to stand unsupported on a weak or paralyzed limb. The inability to bear weight will cause the client to fall.
The nurse is caring for a child who will require the use of an apnea monitor when discharged from the hospital. Which information should the nurse provide to the child's caregiver about the use of an apnea monitor? Select all that apply. 1.Keep leads on the child at all times. 2.Place the monitor inside the child's crib. 3.Adjust the monitor to eliminate false alarms. 4.Sleep in the same bed as the monitored infant. 5.Keep pets and children away from the monitor. 6.Keep emergency rescue numbers near the telephone.
5. Keep pets and children away from the monitor 6. Keep emergency rescue numbers near the telephone
The nurse is admitting a homeless man who was brought to the emergency department by paramedics. He was found unresponsive next to the back door of a restaurant, was unkempt in appearance, and had various scratches on his body. The nurse develops a plan of care for the client. Which priority client problems apply? Select all that apply. 1.Confusion because of homelessness 2.Risk for unsafe conditions because of homelessness 3.Anxiety when consciousness is regained because of the unfamiliar surroundings 4.Lack of knowledge regarding hygiene because of the client's unkempt condition 5.Risk for infection because of his unkempt condition, various scratches, and homelessness
2.Risk for unsafe conditions because of homelessness 3.Anxiety when consciousness is regained because of the unfamiliar surroundings 5.Risk for infection because of his unkempt condition, various scratches, and homelessness Rationale: Infection is a priority because of the client's poor hygiene, altered skin integrity, and homelessness. Injury is also a concern because of the client's situation (homelessness). Waking up in an unfamiliar place can lead to anxiety. No data in the question indicate that the client has confusion or lacks knowledge.
A home care nurse provides medication instructions to a client. What is the appropriate nursing action to ensure safe administration of medication in the home?1.Conduct pill counts on each home visit. 2.Demonstrate the proper procedure to take prescribed medications. 3.Instruct the client to double up on medications if a dose has been missed. 4.Have the client verbalize and demonstrate the correct administration procedures
4.Have the client verbalize and demonstrate the correct administration procedures Rationale: To ensure safe administration of medication, the nurse allows the client to verbalize and demonstrate correct procedure and administration of medications. Demonstrating the proper procedure for the client does not ensure that the client can safely perform this procedure. It is not acceptable to double up on medication, and conducting a pill count on each visit is not realistic or appropriate.
The nurse is preparing to care for a client with esophageal varices who needs a Sengstaken-Blakemore tube inserted because other treatments were unsuccessful. The nurse gathers supplies, knowing that which item must be kept at the bedside at all times? 1.An obturator 2.A Kelly clamp 3.An irrigation set 4.A pair of scissors
A pair of scissors
The nurse is preparing to administer 1 mg of hydromorphone, a Schedule II opioid. The medication is available in a premeasured syringe of 2 mg/mL. Which action by the nurse is correct? 1.Return the unused portion of the medication to the pharmacy. 2.Ask a second nurse to witness disposal of the unused portion. 3.Administer the 1-mg dose and save the remainder for the next dose. 4.Administer the 1-mg dose and discard the unused portion of medication.
Ask a second nurse to witness disposal of the unused portion.
The nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the nurse inflates the balloon, the client complains of discomfort. The nurse should take which appropriate action? 1. Aspirate the fluid, remove the catheter, and insert a new catheter. 2.Aspirate the fluid, advance the catheter farther, and reinflate the balloon. 3.Remove the syringe from the balloon; discomfort is normal and temporary. 4.Aspirate the fluid, withdraw the catheter slightly, and reinflate the balloon.
Aspirate the fluid, advance the catheter farther, and reinflate the balloon.
The nurse is developing a plan of care for a client receiving a nasogastric (NG) tube feeding. When formulating the plan of care, what should the nurse consider? 1.Aspiration is a concern with an NG tube feeding. 2.The client needs to be maintained in a supine position. 3.The NG tube needs to be changed with every other feeding. 4.The rate of the feeding needs to be increased if the infusion rate falls behind schedule.
Aspiration is a concern with an NG tube feeding.
The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action? 1.Prepare the triage rooms. 2.Activate the emergency response plan specific to the facility. 3.Obtain additional supplies from the central supply department. 4.Obtain additional nursing staff to assist in treating the casualties.
Activate the emergency response plan specific to the facility
The nurse purchases a cup of coffee, a bottle of water, and a bagel in the hospital cafeteria and then returns to the nursing unit to take a morning break in the staff lounge. On entering the lounge, the nurse notes that the cushion of a chair is on fire. What should the nurse's first action be? 1.Activate the fire alarm. 2.Quickly pour the coffee on the fire. 3.Open the bottle of water and throw it on the fire. 4.Grab a fire extinguisher and attempt to put out the fire.
Activate the fire alarm
The nurse discovers a fire in the trash basket in a client's bathroom. The nurse assists the client out of the hospital room to a safe place, activates the fire alarm, and takes which action next? 1.Extinguishes the fire 2.Activates the fire alarm 3.Pulls the pin on the fire extinguisher 4.Closes the doors to the other clients' rooms
Activates the fire alarm
The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride using an IV infusion pump. While preparing to plug the pump cord into the wall, the nurse finds that no receptacle is available in the wall socket. The nurse should take which action? 1.Initiate the IV line without the use of a pump. 2.Contact the electrical maintenance department for assistance. 3.Plug in the pump cord in the available plug above the room sink. 4.Use an extension cord from the nurses' lounge for the pump plug.
Contact the electrical maintenance department for assistance
The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride and plans to use an IV infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action? 1.Initiate the IV line without the use of a pump. 2.Contact the electrical maintenance department for assistance. 3.Plug in the pump cord in the available plug above the room sink. 4.Use an extension cord from the nurses' lounge for the pump plug.
Contact the electrical maintenance department for assistance.
The nurse working in the emergency department (ED) is assessing a client who recently returned from Liberia and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next? 1.Check the client's temperature. 2.Check a complete set of vital signs. 3.Isolate the client in a private room. 4.Contact the primary health care provider.
Isolate the client in a private room
A client who is receiving therapy with a hypothermia blanket starts to shiver. The nurse raises the blanket temperature and monitors the client. After 15 minutes the client's temperature has not increased, and the client is still shivering. What should the nurse do next? 1.Apply a smaller heating pad to the client's axillae and neck areas. 2.Wait 10 more minutes and then check the client's temperature again. 3.Remove the hypothermia blanket and notify the client's primary health care provider. 4.Increase the blanket's temperature again and recheck the client's temperature in 15 minutes.
Remove the hypothermia blanket and notify the client's primary health care provider.
The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? 1.Adhering to the mandatory abuse reporting laws 2.Notifying the case worker of the family situation 3.Removing the client from any immediate danger 4.Obtaining treatment for the abusing family member
Removing the client from any immediate danger