Chapter 38

"As a member of the hospital's bioterrorism team, the nurse understands the importance of knowing how an organism is transmitted. Smallpox has the potential to spread quickly because it is transmitted via which route? A) Airborne B) Ingestion C) Absorption D) Blood-borne"

A - Organisms with an airborne route of transmission can claim many victims and spread very quickly. Smallpox is not spread via blood. There is no such thing as an absorption or ingestion route of transmission.

"The nurse delegates to an unlicensed assistant the task of removing the restraints from the client's wrists every ________ hours and reporting any abnormalities. A) 2 B) 4 C) 6 D) 8"

A - Removal of restraints and inspection of the contact area every 2 hours is a requirement of The Joint Commission. The time periods in the other options are too long. The client could experience a serious complication if restraints are not removed and the area under the restraints inspected frequently.

"A student nurse is designing a health fair project aimed at reducing motor vehicle accidents. For which group of clients would this subject be most appropriate? A) Adolescents B) Older adults C) Middle-aged adults D) School-aged children"

A - The risk of motor vehicle accidents is higher among teen drivers than in any other age group.

"Health care workers who have direct contact with individuals suspected of being contaminated with anthrax should do which of the following? (Choose all that apply.) A) Wear an isolation gown, gloves, and high-efficiency particle arrestor (HEPA) mask B) Prepare the client for transfer to the radiology department for chest radiography C) Instruct the client to wash the hands and exposed areas with soap and water D) Have the client remove clothing and place it in a sealed biohazard bag"

A, D - Anthrax is caused by a spore-forming, gram-positive bacillus. Humans become infected through skin contact, ingestion, and inhalation. The nurse should wear an isolation gown, gloves, and a high-efficiency particle arrestor (HEPA) mask. The client should remove potentially contaminated clothing for testing and decontamination. The client should remain in isolation until it is certain that the bacteria have been contained, not transferred to radiology. The client should shower thoroughly with soap and water, not just wash hands and exposed areas.

While the nurse is administering flu immunizations in November to a group of older adults at a community senior citizens' center, one of the seniors expresses a fear of contracting the flu from the injection. The nurse reassures the senior that this is not possible because the vaccine contains a dead virus and explains that this injection will produce _________ immunity, in which the senior's body will make antibodies to the virus.

Active

"When providing health maintenance teaching to new employees in the food-handling department, the nurse emphasizes the need to perform hand hygiene after using the bathroom to prevent: A) Food poisoning B) Spread of hepatitis A C) Bacterial food infections D) Salmonella contamination"

B - The hepatitis A virus is spread via fecal contamination of food, water, or milk. It is essential that food handlers wash their hands anytime they use the bathroom. Food poisoning can be due to bacterial contamination of food from a variety of sources, but not usually feces. Salmonella contamination usually arises from uncooked eggs.

"A parent calls the pediatrician's office frantic because her 2-year-old son drank a bottle of cleaner. Which of the following is the most important instruction the nurse can give to this parent? A) Give the child milk. B) Call the poison control center. C) Give the child syrup of ipecac. D) Take the child to the emergency department."

B - The poison control center will direct all care given to a child who has ingested a substance. Based on the description of the poison, poison control center staff will tell the parent whether the child needs to go to the emergency department and what substances should be given to the child.

"The family of the nurse's confused, ambulatory client insists that all four side rails be up when the client is alone. The best way to handle this situation is to: A) Ask them to stay with the client at all times. B) Inform them of the risks associated with side rail use. C) Thank them for being conscientious and put the four rails up. D) Provide the client with a one-to-one sitter while the side rails are up."

B - The use of side rails when a client is disoriented will cause more confusion and further injury. A confused client who is determined to get out of bed may attempt to climb over the side rail or climb out at the foot of the bed, and may fall or experience other injury. After the nurse has this discussion with the family, then the nurse should perform a thorough nursing assessment and develop a plan to ensure the client's safety.

"The nurse discovers an electrical fire in a client's room. The nurse's first action would be to: A) Activate the fire alarm. B) Confine the fire by closing all doors and windows. C) Evacuate any clients or visitors in immediate danger. D) Extinguish the fire by using the nearest fire extinguisher."

C - The nurse's first step when a fire is discovered is to evacuate any clients or visitors in immediate danger. Then the nurse should activate the fire alarm, confine the fire, and then extinguish it.

"A couple has brought in their adolescent daughter for a school physical. The parents tell the nurse that they are worried about all the safety risks for this age group. As the nurse plans to teach the parents about these risks, the nurse remembers that adolescents are at a greater risk for injury from: A) Home accidents B) Poisoning and child abduction C) Physiological changes of aging D) Automobile accidents, suicide, and substance abuse"

D - Adolescents are more likely to be involved in automobile accidents, commit suicide, and engage in substance abuse than are those in other age groups. Children are more susceptible to poisoning and child abduction, and older adults are more susceptible to home accidents and the physiological changes of aging.

"A child for which the nurse is caring in the hospital starts to have a grand mal seizure while playing in the playroom. What is the most important intervention the nurse can do during this situation? A) Begin cardiopulmonary resuscitation. B) Restrain the child to prevent injury. C) Place a tongue blade over the tongue to prevent aspiration. D) Clear the area around the child to protect the child from injury."

D - An area around the child should be cleared to prevent injury. Restraining the child or placing a tongue blade in the child's mouth may actually be a cause of injury. Cardiopulmonary resuscitation is required only if heart function stops after the seizure.

"During the night shift a client is found wandering the hospital halls looking for a bathroom. The nurse's initial intervention would be to: A) Insert a urinary catheter. B) Ask the physician to order a restraint. C) Assign a staff member to stay with the client. D) Provide scheduled toileting during the night shift."

D - Providing scheduled toileting during the night makes it less likely that a client will wander while being confused and ensures staff presence to decrease confusion at the times when the client is away from bed. Inserting a urinary catheter is not necessary. Assigning a staff member to stay with the client might not be necessary if the scheduled toileting is successful. Restraints are unnecessary in this case.

"During the nurse's assessment of a 56-year-old man, he reports increased alcohol consumption because of stress at work. One of the expected outcomes for this client will be to: A) Decrease stress in his life. B) Teach him ways to promote sleep. C) Decrease his alcohol intake during times of stress. D) Provide the client with information about stress management classes."

D - Resources for stress management and sleep promotion can help accomplish reduced alcohol intake during times of stress in the client's life. Management of stress is the expectation, but decreasing stress may not be possible.

"After the nurse assists a client with a history of seizures to a recliner chair, the client begins to have a seizure. The nurse should immediately: A) Turn the client onto his or her stomach. B) Recline the client's chair all the way back. C) Return the client to the bed and place the client on his or her side. D) Slide the client to the floor and cradle the client's head in the nurse's lap."

D - The nurse's lap is the safest position for the client's head, and the client is less likely to sustain an injury if the client is already on the floor. Attempting to move the client laterally by oneself could result in injury to the client and/or nurse. Placement in a reclining position could cause excess secretions to accumulate in the oral pharynx and obstruct the airway. Turning the client onto his or her stomach would decrease access to the airway.

"Lisa, a nurse assistant, is working with the nurse during the nurse's shift. One of the nurse's clients has upper limb restraints. In delegating care of this client to Lisa, the nurse would tell her to: A) Secure the restraints to the side rails. B) Check to see if the client can have a medication for sleep. C) Call the physician if the client becomes more agitated with the restraint. D) Report any signs of redness, excoriation, or constriction of circulation under the restraint."

D - The restraint sites much be checked regularly for signs of redness, excoriation, or constriction, and this task may be delegated. Calling the physician and performing medication assessments are nursing responsibilities. Restraints should never be secured to the side rails.