Saunders- Health and Physical Safety Hygiene & Safety

The nurse is planning to feed an older client who is at risk for aspiration of food. During the meal how should the nurse position the client?

Upright in a chair

Upon palpation of the fontanel of a 3-month-old newborn, the nurse notes that the anterior fontanel has not closed and is soft and flat. Which action should the nurse take?

Document the findings.

While collecting data related to the cardiac system on a client, the nurse hears a murmur. Which best describes the sound of a heart murmur?

Gentle, blowing or swooshing noise

The nurse is preparing to collect client data by examining the abdomen. The nurse should begin the assessment by performing which action first?

Inspecting the abdomen

The nurse is reinforcing instructions to a client about safety measures while using oxygen in the home. The nurse determines that there is a need for further teaching if the client verbalized which statement?

Keep the oxygen concentrator as close to the room wall as possible.

The nurse is caring for a client who becomes agitated and begins to pull on a surgically placed abdominal drainage tube. The primary health care provider visits and prescribes restraints if needed. Which actions are appropriate to delegate to the unlicensed assistive personnel (UAP), who has completed the facility's education about care of the restrained client? Select all that apply.

Socialize with the restrained client. Remove the restraint and perform range of motion activity. Reapply the restraint after assisting the client to the bathroom.

The nurse is monitoring the laboratory results of a female client receiving an antineoplastic medication by the intravenous (IV) route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?

A platelet count of 40,000 mm3 (40 × 109/L)

The nurse is preparing to perform an abdominal examination. Which step should be taken first?

Inspection

The nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of data collection? Select all that apply.

Listening to lung sounds Obtaining the client's temperature Obtaining information about the client's respirations

The nurse is changing the neck ties on a tracheostomy tube. Which method is appropriate for the nurse to take?

Remove the old ties, clean the site, and then apply the new ties while a second health care team member holds the tracheostomy tube.

A 1-year-old infant is admitted to the hospital for control of tonic-clonic seizures. The nurse helps minimize the infant's risk for injury by implementing which interventions? Select all that apply.

Removing any toy with bright blinking lights Keeping the sides rails of the child's bed padded Turning the infant on the side during any seizure

The nurse is assigned to assist in caring for a client who has had surgery and has pneumatic sequential compression devices (SCDs) in place. The client asks about these devices. The nurse instructs the client that SCDs are used for which purpose?

Promoting venous return to the heart

The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the intravenous (IV) of an assigned client who is receiving fluid replacement therapy how frequently?

every hour

The nurse is teaching the paraplegic client measures to promote skin integrity. Which instructions would be helpful to the client? Select all that apply.

1. Eat a nutritious diet. 2. Use a pressure relief pad while in a wheelchair. 4. Check the bottom sheet for wetness and wrinkles.

Which client is the safest one for a licensed practical nurse (LPN) to care for?

A client recovering from a scheduled cesarean delivery

The nurse employed in the ambulatory care department hears a client in the waiting room call out, "Help, fire!" The nurse rushes to the waiting room and finds the wastebasket on fire. Which is the immediate action of the nurse?

Remove the clients from the waiting room.

The nurse is told that a client will be admitted to the hospital for a radiation implant. The nurse is asked to prepare for the admission of the client and plans which measure for this client?

Admit the client to a private room.

The nurse is preparing to get a client with tetraplegia (quadriplegia) out of bed into a chair. The nurse places which item on the seat of the chair as the best device for pressure relief?

Alternating air pad

A client is being discharged to home following spinal laminectomy and fusion with insertion of a metal implant. The nurse includes which instructions about activity after discharge? Select all that apply.

Avoid activities that involve pulling or pushing. Do not lift objects weighing more than 5 pounds. Do not climb stairs until after the follow-up appointment with the surgeon.

The nurse is preparing to clean up a blood spill on the client's bedside table. The spill occurred when a blood tube containing the client's blood specimen broke. The nurse avoids doing which action when cleaning up the blood spill?

Blotting up the spill with a face cloth or cloth towel

The nurse is caring for a client who is receiving an intermittent feeding via a nasogastric (NG) tube. Before feeding the client via the NG tube, the nurse should take which actions? Select all that apply.

Check the placement of the tube. Aspirate the contents from the nasogastric tube. Observe the characteristics and pH of the aspirate from the nasogastric tube.

The nurse is caring for a child following a cleft palate repair who has elbow restraints in place. The nurse assists in preparing a plan of care and determines that which nursing intervention should receive highest priority regarding the restraints?

Checking color, sensation, and pulses distal to the restraints

The nurse is auscultating bowel sounds. Which are appropriate data collection methods and actions? Select all that apply.

Divide the abdomen into four quadrants at the umbilicus. Do not feed the client if no sounds are audible in 5 minutes. Listen in each quadrant for gurgling sounds indicating movement.

While caring for a client admitted to the hospital with suspected seizure activity, the client acknowledges the use of the herbal supplement ginkgo, to the nurse. Which follow-up questions by the nurse would be most appropriate? Select all that apply.

Do you have a history of seizures? How long have you been using ginkgo? Do you have a history of a clotting disorder? Have you been diagnosed with diabetes mellitus?

The nurse is preparing the client for eye testing, and the examiner is planning to test the eyes using the confrontational method. What should the nurse tell the client about the purpose of the test?

Examines visual fields or peripheral vision

A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed linens changed. Which should the nurse wear to perform these tasks?

Gown and gloves

The nurse is inquiring about the client's use of complementary and alternative medicines (CAMs). The nurse should be most concerned with the client who uses which CAMs? Select all that apply.

Homeopathy Herbal supplements

The nurse is preparing to administer an acetaminophen suppository to a child. The nurse plans which action?

Insert the suppository 1 to 2 cm into the rectum.

The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care to a client. Which instructions should be included in the list? Select all that apply.

Obtain a Medic-Alert bracelet. Prevent debris from entering the stoma. Avoid exposure to people with infections. Avoid swimming and use care when showering.

The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which data specifically associated with this therapy before the initiation of therapy? Select all that apply.

Pedal pulses Capillary refill Color of the extremity Temperature of the skin

The nurse is reinforcing instructions for a client in how to perform a testicular self-examination (TSE). Which instructions should the nurse include? Select all that apply.

Place two fingers under the restraint to determine snugness.

A client who is recovering from a brain attack (stroke) has residual dysphagia and is prescribed nectar thickened liquids. The licensed practical nurse has instructed the unlicensed assistive personnel (UAP) in feeding technique. The nurse should intervene if the UAP attempts to perform which activity?

Placing food on the affected side of the mouth

The nurse is assigned to care for a client experiencing episodes of postural hypotension who will be discharged home soon. Which actions should the nurse take to ensure safety while transferring the client from the bed to the chair? Select all that apply.

Question the client about feelings of dizziness. Put the client's shoes on to help the client avoid slipping on the floor during the transfer. Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.

A client with a diagnosis of tonic-clonic seizures is being admitted to the hospital, and the nurse needs to institute seizure precautions. During a seizure, which items are inappropriate to use and could cause harm to the client? Select all that apply.

Restraints. Padded tongue blade

The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula at 2L. To provide a safe delivery of the oxygen the nurse should avoid which actions? Select all that apply.

Securing the oxygen tubing to the client's bottom sheet Positioning the nasal prongs in the nares and adjusting the plastic slide on the cannula so that the cannula fits as tight as possible

The nurse is assigned to care for a client who has a nasogastric (NG) tube and is receiving tube feedings. When implementing nursing care for the client, the nurse remembers which information? Select all that apply.

That aspiration as a complication is a primary concern To determine correct placement by aspirating contents from the tube to observe characteristics and check pH

The nurse is asked to test the visual acuity of a client using a Snellen chart. The nurse prepares to perform the test, knowing that which procedure accurately identifies this visual acuity test?

The right eye is tested, followed by the left eye, and then both eyes are tested.

The nurse assists in conducting a home safety assessment with a client preparing for discharge. The client tells the nurse that a space heater is used to heat part of the apartment. Which instruction should the nurse provide to the client regarding the use of the space heater?

The space heater needs to be placed at least 3 feet from anything that can burn.

The registered nurse (RN) and a licensed practical nurse (LPN) are discussing total parenteral nutrition (TPN) with a client who is receiving TPN through a peripherally inserted central catheter (PICC). The client asks why the solution is being infused through a central catheter IV. The nurses explain that TPN is preferably infused through a central line for which reason?

There is greater blood flow with a central line IV to dilute the TPN, which is a concentrated solution and needs to be diluted to avoid damage to the blood vessel.

The nurse admits a client who has seizure precautions prescribed. The client has a seizure just after the nurse has implemented the precautions. Which actions should the nurse take? Select all that apply.

Time the start and stop of the seizure. Apply oxygen at 2L with nasal cannula. Turn the client to the side and do not restrain. Note the distinguishing characteristics of the seizure. Turn on the suction machine with oral catheter.

The nurse is caring for an older client who had surgery to repair a fractured hip. In the late evening the client becomes slightly confused and is moving about in bed. Which actions should the nurse take initially? Select all that apply.

Turn on the bed alarm. Ask the client about needing to void or move bowels. Turn on the nightlight in the hospital room and bathroom.

The nurse is performing an environmental assessment in the home of an older client. Which observations require immediate attention? Select all that apply.

Unsecured scatter rugs Cigarette pack and lighter on the bedside stand

The nurse is assisting in the care of a client diagnosed with acquired immunodeficiency syndrome (AIDS) who requires an injection. The nurse should include which actions to safely administer the medication? Select all that apply.

Wear gloves while administering the injected medication. Dispose of the needle and syringe in a puncture-resistant container.

The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside?

a pair of scissors

To assess for the presence of the posterior tibialis pulse, the nurse should palpate which areas?

In the groove behind the medial malleolus and the Achilles tendon

The nurse is preparing to administer a medication through a nasogastric (NG) tube that is connected to suction. Which interventions should be included to accurately administer the medication? Select all that apply.

Clamp the NG tube for 30 minutes after medication administration. Before medication administration, verify correct placement of tube. Flush the NG tube with saline before and after medication administration. Discontinue the suction from the tube during administration of medication.

The nurse is preparing to discontinue an indwelling urinary catheter. Which pieces of equipment should the nurse obtain to perform this procedure? Select all that apply.

Clean towel. Sterile 10- or 12-mL syringe

A client who is recovering from a brain attack (stroke) has residual dysphagia and is prescribed nectar thickened liquids. The licensed practical nurse has instructed the unlicensed assistive personnel (UAP) in feeding technique. The nurse should intervene if the UAP attempts to perform which activity?

Perform TSE after a shower or bath. Perform TSE on the same day each month Perform TSE by rolling each testicle between the thumb and fingers.

The nurse is reinforcing instructions provided to a client with a continuous passive motion (CPM) machine. The nurse determines that there is a need for further teaching when the client states that he should perform which action?

Reset the degrees of flexion or extension according to comfort.

The nurse administers an injection to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). After administering the medication, the nurse should dispose of the used needle by which method?

Placing the needle and syringe in a puncture-resistant container

The nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. Based on this finding, the nurse should institute which intervention? Select all that apply.

Collect data to determine factors for fall risk. Instruct the client to ask for assistance when getting up to walk.

A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing?

Closes the roller clamp on the IV tubing

The nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further teaching?

"I need to be sure to place my cup of coffee on the counter."