Exam 1: QSEN-Safety Questions

The registered nurse is teaching a student nurse about the interventions to be followed by a client to prevent the spread of infection. Which statement made by the student nurse indicates the need for further learning? 1. "I will advise the client to squeeze the pustules." 2. "I will advise the client to bathe daily with an anti-bacterial soap." 3. "I will advise the client to remove crusts before applying topical drugs." 4. "I will advise the client to apply warm compresses to areas of cellulites."

1 rationale: The client should not squeeze the pustule as it contains pus and squeezing may cause the spread of bacterial infections to unaffected areas. Taking daily baths with an anti-bacterial soap reduces and prevents the spread of infection. The crusts should be gently removed before applying topical drugs so that drugs can be easily absorbed. Applying warm compresses to areas of cellulites increases comfort.

Which herbal remedies used by clients of Mexican descent should the nurse include in the assessment process to determine the source of lead poisoning for a toddler-age client? Select all that apply. 1. greta 2. surma 3. azarcon 4. lozeena 5. tamarindo jellied fruit candy

1, 3, 5 rationale: Greta, Azarcon, and Tamarindo jellied fruit candy may all be sources of lead for a toddler-age client who is of Mexican descent; therefore, the nurse should include these items in the clients' assessment. Surma and Lozeena use is not an herbal remedy used by clients of Mexican descent.

Selegiline is prescribed for a client with Parkinson disease who is having an inadequate response to levodopa therapy. What information does the nurse include when teaching the client about the addition of this drug to the regimen? 1. Primary healthcare provider should be contacted immediately if a severe headache occurs. 2. Therapeutic blood level of the drug should be monitored each month. 3. Dosage of the drug can be adjusted daily depending on the client's response that day. 4. Side effects of levodopa will decrease when the selegiline and levodopa are taken concurrently.

1 rationale: A severe headache is a sign of a monoamine oxidase inhibitor-induced hypertensive crisis and should be reported to the healthcare provider immediately. Monthly blood tests are unnecessary, but routine medical evaluations of the client should be scheduled. Adjusting the dose of the drug daily is unsafe; the recommended daily dose of the drug should be taken as prescribed. The side effects of levodopa will increase, not decrease, when these two drugs are taken concurrently.

A nurse in the emergency department is caring for a 9-year-old child with a suspected spinal cord injury sustained while falling off a bicycle. What is the initial nursing action? 1. Placing the child's head on a pillow for support 2. Immobilizing the child's spine to limit additional injury 3. Log-rolling the child to check for lacerations on the back 4. Moving the child onto a firm stretcher for transport to the radiography department

2 rationale: Immobilization of the spine is most important to minimize additional injury while the child is being assessed. Placing a pillow under the head is contraindicated because the vertebral column and spinal cord might move, resulting in additional damage to the spinal cord. Log-rolling is unsafe without prior immobilization of the spine, as is moving the child.

When should the nurse use hypoallergenic tape or Montgomery straps as the best practice in postoperative skin care? 1. When conserving the client's energy 2. When protecting the fragile skin of the older client 3. When maintaining the psychosocial health of the older client 4. When improving perfusion to the wound to promote wound healing

2 rationale: The nurse should use hypoallergenic tape or Montgomery straps to protect the fragile skin of the older client. To conserve the client's energy, the nurse should allow the client to sleep in a darkened, quiet room. To maintain the psychosocial health of the older client, the nurse should allow the client liberal visitation by supportive persons. To improve perfusion to the wound to promote wound healing, the nurse should keep the client adequately hydrated to maintain cardiac output.

Which statement should the nurse make when providing information to the parent of a preschool-age client who calls the pediatric clinic after dropping a mercury thermometer at home? 1. "Hang up and call 9-1-1 for further treatment." 2. "Contact the poison control center immediately." 3. "Clean up the spill using paper towels and disposable gloves." 4. "Bring your child to the clinic immediately for further assessment."

3 rationale: After dropping a mercury thermometer at home, the nurse would tell the parent to clean up the spill using paper towels and disposable gloves to avoid the risk of inhalation injury for the preschool-age client. There is no reason to activate emergency medical services, contact the poison control center, or bring the child to the clinic for further assessment after dropping a mercury thermometer at home.

A client is to take an antipsychotic drug twice a day. Two-thirds of the daily dose is given in the evening and one-third in the morning. What will the nurse tell the client is the rationale for this schedule? 1. to facilitate dreaming 2. to maintain the daily sleep rhythm 3. to reduce sedation during the daytime 4. to decrease assaultiveness in the evening

3 rationale: Antipsychotic drugs tend to make the client listless or drowsy and can interfere with the ability to participate in the therapeutic regimen. Antipsychotic drugs do not induce rapid eye movement sleep, which is when most dreams occur. Antipsychotic drugs do not appreciably affect diurnal rhythms. Assaultiveness is associated with increased anxiety and is unrelated to the time of day.

When discussing a scheduled liver biopsy with a client, the nurse explains that for several hours after the biopsy the client will have to remain in what position? 1. The left side-lying position with the head of the bed elevated 2. A high-Fowler position with both arms supported on several pillows 3. The right side-lying position with pillows placed under the costal margin 4. Any comfortable recumbent position as long as the client remains immobile

3 rationale: In the right side-lying position with pillows placed under the costal margin, the liver capsule at the entry site is compressed against the chest wall, and escape of blood or bile is impeded. The left side-lying position with the head of the bed elevated, a high-Fowler position with both arms supported on several pillows, and any comfortable recumbent position as long as the client remains immobile are unsafe because pressure will not be applied to the puncture site and the client can bleed from the insertion site.

After a cleft lip repair a nurse places elbow restraints on the infant. The parents ask the nurse, "Why does our child have to have restraints?" How should the nurse respond? 1. they're used routinely on infants who have had lip surgery 2. legally we're required to put them on infants after lip surgery 3. the staff can't be with your baby continuously to prevent touching of the mouth 4. because we're keeping the arms straight, your baby won't be able to touch the mouth

4 rationale: An explanation of how the restraints work and why they are used may reassure the parents. Touching the suture line may cause a separation of the wound edges, predisposing the infant to infection and compromised wound healing. Explaining routine use of restraints does not explain why they are being used now. Restraints are not a legal requirement; applying elbow restraints is a postoperative prescription. Stating that the nurse cannot be with the infant continuously may give the parents the feeling that their baby's needs are not being met.

While caring for a client who was injured in a tornado, the nurse finds that the client is disoriented. Which is the most appropriate nursing intervention to prevent injury in the client? 1. Keeping rails up on the stretcher 2. Keeping the stretcher in lowest position 3. Maintaining adequate lightening in the room 4. Asking a family member to remain with the client

4 rationale: Asking a family member or significant person who cares for the client to remain with the client will help to reduce confusion in the client. It is the most important intervention to prevent injury in the client. Keeping rails up on the stretcher will help to prevent injury in the client but it is not the most appropriate intervention. Keeping the stretcher in the lowest position will prevent injury but it is not the most appropriate intervention in clients. Maintaining adequate lighting in the room will help to prevent injury from a fall but it is not the most appropriate intervention in case of disoriented or confused clients.

which drug used to treat acne has a bleaching effect? 1. isotretinoin 2. minocycline 3. tetracycline 4. benzoyl peroxide

4 rationale: Benzoyl peroxide has a bleaching effect on sheets, bedclothes, and towels. Isotretinoin is associated with photosensitivity, nasal irritation, dry skin and mucous membrane. Minocycline and tetracycline are systemic antibiotics that may cause photosensitivity reactions, vaginal candidiasis, and gastrointestinal upset.

After surgery a 2-month-old infant is returned to the pediatric unit with an intravenous infusion running and a nasogastric tube in place. What is the initial nursing action? 1. Assessing the infant's status 2. Giving the infant a mild sedative 3. Connecting the nasogastric tube to wall suction 4. Placing the intravenous tubing through an infusion pump

1 rationale: Assessment, the first step of the nursing process, is the priority because it influences all future interventions. The infant's respiratory status and vital signs should be assessed before a sedative is administered. Although it is important to attach the nasogastric tube to a suction device, this may be done after the infant's status has been assessed. Although it is important to connect the intravenous line to a pump, this may also be done after the infant's status has been assessed.

A parent brings a 2-week-old infant to the clinic because the infant continually regurgitates. Chalasia, an incompetent cardiac sphincter, is suspected. What instructions should the nurse give the parent? 1. Keep the infant in an upright position after feedings. 2. Prevent the infant from crying for prolonged periods. 3. Keep the infant in the prone position after each feeding. 4. Ensure that the infant drinks a full bottle of formula at each feeding.

1 rationale: Chalasia allows reflux of gastric contents into the esophagus and eventual regurgitation. Placing the infant in an upright position keeps the gastric contents in the stomach by means of gravity and limits the pressure against the cardiac sphincter. Preventing the infant from crying for prolonged periods will probably have little effect on chalasia. Keeping the infant in the prone position after feedings will promote regurgitation; it is also unsafe because of the danger of sudden infant death syndrome. Ensuring that the infant drinks a full bottle of formula at each feeding will promote vomiting; the infant should be allowed to stop feeding when satiated, not when the bottle is empty.

The nurse is caring for four clients admitted at once under mass casualty conditions. Which client should be treated first? 1. A 2. B 3. C 4. D

1 rationale: Client A with an airway obstruction has an immediate threat to life and the condition is considered emergent, which meets the criteria for class 1. Client B with extensive full thickness burns should be triaged under class 4 because the condition is considered to be expectant and the client will die. Client C with open fractures implies a major injury that requires treatment and is considered urgent. This client is triaged under class 2. Client D with a closed fracture and abrasions indicates a minor injury that does not require immediate treatment and is triaged under class 3.

A nurse is assessing an adolescent after the administration of epinephrine. What side effect is most important for the nurse to identify? 1. Tachycardia 2. Hypoglycemia 3. Constricted pupils 4. Decreased blood pressure

1 rationale: Epinephrine is a sympathetic nervous system stimulant that causes tachycardia. Hyperglycemia, not hypoglycemia, may result. The pupils will be dilated, not constricted. Epinephrine is more likely to cause hypertension than hypotension.

What is the most appropriate response by a nurse to a parent's question about childhood suicide? 1. "Suicide threats in children should be taken seriously." 2. "Children do not have readily available means to kill themselves." 3. "Children younger than age 6 may threaten but don't attempt suicide." 4. "Suicide attempts in young children are manipulative behaviors to control their parents."

1 rationale: Suicide threats and gestures are a means of communicating anger, frustration, hopelessness, and despair to significant others and should always be taken seriously. Children have many means readily available; many common objects around the home and playground can be used to commit suicide. Although suicide is the second leading cause of death in the 15- to 24-year-old group, children younger than age 6 do attempt suicide, and some succeed. A suicide attempt is usually self-destructive; it is not an attempt to manipulate or control others.

A nurse is teaching the parents of an infant with eczema about the foods that are most allergenic. What foods should the nurse instruct the parents to eliminate from the diet? Select all that apply. 1. Milk 2. Eggs 3. Apples 4. Peanuts 5. Bananas

1, 2, 4 rationale: Milk and eggs contain protein to which the eczematous child may be allergic. Peanuts are highly allergenic. Apples and bananas rarely cause an allergic reaction.

An agitated, acting-out, delusional client is receiving large doses of haloperidol, and the nurse is concerned because this drug can produce untoward side effects. Which clinical manifestations will alert the nurse to stop the drug immediately? Select all that apply. 1. jaundice 2. dizziness 3. tachycardia 4. lethargic behavior 5. extrapyramidal symptoms

1, 3 rationale: Jaundice signifies liver function interference and requires that the medication be stopped. Tachycardia, QT-interval prolongation, and cardiac arrest are life-threatening cardiovascular effects of haloperidol (Haldol). Dizziness due to orthostatic hypotension usually subsides after several weeks of treatment. Lethargy and drowsiness usually subside after several weeks of treatment. Extrapyramidal symptoms usually require that the dose be reduced or can be treated with other medications; if symptoms do not subside, then the drug is stopped.

A nurse prepares to administer prednisone to a 4-year-old child who weighs 48 lb (21.8 kg). The dose for children is 2 mg/kg/day in four divided doses. How much prednisone will the nurse administer for one dose? Round your answer to nearest whole number. ___ mg

48lb / 2.2 = 21.8 kg 2 mg x 21.8 kg = 43.6 mg/day 43.6 mg / 4 = 10.9 mg rounded to nearest whole number = 11 mg/dose

A primary healthcare provider prescribes 0.25 mg of alprazolam by mouth three times a day for a client with anxiety and physical symptoms related to work pressures. For what most common side effect of this drug will the nurse monitor the client? 1. drowsiness 2. bradycardia 3. agranulocytosis 4. tardive dyskinesia

1 rationale: Alprazolam, a benzodiazepine, potentiates the actions of gamma-aminobutyric acid, enhances presympathetic inhibition, and inhibits spinal polysynaptic afferent pathways. Drowsiness, dizziness, and blurred vision are common side effects. Alprazolam may cause tachycardia, not bradycardia. Agranulocytosis is usually a side effect of the antipsychotics in the phenothiazine, not the benzodiazepine, group. Tardive dyskinesia occurs after prolonged therapy with antipsychotic medications; alprazolam is an antianxiety medication, not an antipsychotic.

A client with dementia has been cared for by the spouse for 5 years. During the last month the client has become agitated and aggressive and is incontinent of urine and feces. What is the priority nursing care while this client is in an inpatient mental health facility? 1. managing the behavior 2. preventing further deterioration 3. focusing on the needs of the spouse 4. establishing an elimination retraining program

1 rationale: The client must be kept from harming self or others and needs a calm, supportive environment that meets needs and maintains dignity. Alzheimer dementia is characterized by progressive deterioration that is not preventable; however, some drugs such as donepezil may slow mild to moderate dementia. Although addressing the needs of family members is important, the focus of care is primarily on the client. Establishing an elimination retraining program may be unrealistic and is not the priority.

A 4-year-old child is admitted to the pediatric neurologic service with a seizure disorder. Shortly after admission, while in bed, the child has a generalized seizure. What nursing actions are most appropriate? Select all that apply. 1. assessing the seizure 2. taking the child's vital signs 3. turning the child on the side 4. pulling the padded side rails up 5. initiating oxygen administration

1, 3, 4 rationale: Therapeutic management is based on an accurate description of the seizure. Turning the child on one side or the other allows drainage of secretions that cannot be swallowed during the seizure. The first safety precaution is to prevent injury by raising the padded side rails. It is impossible to take vital signs during a seizure. Administering oxygen is useless because the child does not breathe during a seizure.

An 8-year-old child with a history of asthma is brought to the emergency department because of respiratory distress. The nurse immediately places the child in a bed with the head of the bed elevated and administers oxygen by means of a face mask. The healthcare provider performs a physical assessment, writes prescriptions, and admits the child to the pediatric unit. Which instruction should the nurse carry out first? 1. Teach incentive spirometer use. 2. Administer the nebulizer treatment. 3. Obtain a blood specimen for a complete blood count. 4. Notify the respiratory therapist to perform chest physiotherapy.

2 rationale: Albuterol (Proventil) relaxes smooth muscles in the respiratory tract, resulting in bronchodilation. The priority is to facilitate respiration, and this intervention follows the ABCs of emergency care—airway, breathing, and circulation. The use of an incentive spirometer may be taught after the acute episode of respiratory distress has been resolved. It will take time to obtain the device and teach the child about its use, and it should be used after the airway has been opened. Obtaining a blood specimen is not the priority. The results will not influence the priority intervention. Notifying the respiratory therapist is not the priority. Chest physical therapy is performed after the airway has been opened.

Which client in a psychiatric unit needs immediate therapeutic intervention from the nurse? 1. A 25-year-old man who is mimicking the use of a machine gun in front of the nurse's station 2. A 45-year-old man who is sitting quietly in the corner, watching the movements of other clients 3. A 50-year-old woman who is pacing back and forth across the dayroom and picking fights with other clients 4. A 33-year-old woman who wanders aimlessly around the unit, saying, "I just don't know what to do. I feel so lost."

3 rationale: The pacing client is demonstrating increased agitation and poses an immediate threat to the safety of other clients. The behavior requires immediate nursing intervention to prevent injury to herself or others. Although the client mimicking the use of a gun is probably hallucinating, he poses no immediate threat to himself or others. Although the quiet, watchful client may be suspicious, the data given do not indicate that he presents a danger to himself or to others. Although anxious, the client who expresses a feeling of being lost does not represent a threat to herself or others.

A primary healthcare provider prescribes 10 mg of haloperidol by mouth twice a day for a client who is also receiving phenytoin for control of epilepsy. When planning the client's care, the nurse considers that, when anticonvulsants interact with haloperidol, what effect may occur? 1. Masking of haloperidol's therapeutic effect 2. Interference with haloperidol's absorption 3. Enhancement of haloperidol's rate of metabolism 4. Potentiation of haloperidol's central nervous system depressant effect

4 rationale: Antiseizure medications and haloperidol exert a synergistic central nervous system depressant effect. The effect is potentiated, not masked. Anticonvulsants do not affect the absorption or metabolism of haloperidol.

A pyloromyotomy is performed on an infant who has hypertrophic pyloric stenosis. In what position should the nurse teach the mother to place the infant during and after feeding? 1. Supine for feedings; held upright afterward to be burped 2. Side-lying for feedings; rocked afterward to reduce crying 3. At a 45-degree angle for feedings; prone with the upper body elevated afterward 4. At a 90-degree angle for feedings; on the right side with the upper body elevated afterward

4 rationale: During and after feeding, the position that most favors gravity is used to promote retention of fluid, prevent vomiting, and facilitate flow of gastric contents through the pyloric sphincter; therefore, the infant should be placed at a 90-degree angle on the right side with the upper body elevated. Feeding any child in the supine position increases the risk of aspiration. Vomiting may continue after surgery; there should be limited movement after feedings. With the infant in an elevated, not side-lying, position, gravity facilitates retention of the feeding. Although postoperative positioning with the head elevated aids retention of feedings, the prone position is avoided to prevent vomiting and aspiration, as well as sudden infant death syndrome.

The hepatitis B-positive mother of an infant born earlier in the day wants her infant to receive the hepatitis B immune globulin (HBIG) vaccine. What is the proper dosage of this vaccine? 1. 1.0 mL subcutaneously before discharge 2. 0.5 mL subcutaneously within 24 hours of birth 3. 1.0 mL intramuscularly within 24 hours of birth 4. 0.5 mL intramuscularly within 12 hours of birth

4 rationale: HBIG must be given within 12 hours of birth to be effective. The correct dose is 0.5 mL, and it must be given intramuscularly. The vaccine is not given subcutaneously.

The nurse is caring for victims of a bomb blast in the emergency department who are receiving different pain medications. Which client must be placed on electrocardiogram equipment? 1. A 2. B 3. C 4. D

4 rationale: Nonsteroidal antiinflammatory medications such as naproxen may result in cardiovascular events such as myocardial infarction, stroke, and heart failure, so the client who is on naproxen requires continuous assessment of the cardiovascular system. Therefore the nurse places client D on the electrocardiogram equipment. Aspirin does not result in myocardial infarction, stroke, or heart failure, so client A does not need to be on the electrocardiogram equipment. Methadone and butorphanol do not cause cardiovascular risks. Therefore clients B and C do not need to be on electrocardiogram equipment.

Which parental statement indicates the need for further education related to bicycle safety for the school-age client? 1. "My child should ride with the traffic." 2. "My child should walk the bicycle through crosswalks." 3. "My child should use hand signals in advance of stopping." 4. "My child should keep as far from the curb as possible when in the street."

4 rationale: The child should stay as close as possible to the curb when riding a bicycle in the street; therefore, the parental statement indicating the opposite of this indicates the need for further education. The parental statements indicate that the child should ride with traffic, the bicycle should be walked through crosswalks, and the importance of using hand signals prior to stopping all indicate accurate understanding of the information presented.

Phenytoin suspension 200 mg is prescribed for a client with epilepsy. The suspension contains 125 mg/5 mL. How much solution will the nurse administer? Record your answer using a whole number. __ mL

The prescribed dose is 200 mg. The available concentration is 125 mg in 5 mL. Use the dimensional analysis and ratio and proportion methods to determine how many milliliters the nurse should administer.