Exam4 pt2

When making rounds the nurse observes a purple wristband on a patient's wrist. How will the nurse interpret this finding? a. The patient is allergic to certain medications or foods. b. The patient has do not resuscitate preferences. c. The patient has a high risk for falls. d. The patient is at risk for seizures.

ANS: B In 2008 the American Hospital Association issued an advisory recommending that hospitals standardize wristband colors: red for patient allergies, yellow for fall risk, and purple for do not resuscitate preferences. Purple does not indicate seizures.

The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with Clostridium difficile in droplet precautions b. A patient with tuberculosis in airborne precautions c. A patient with MRSA infection in contact precautions d. A patient with a lung transplant in protective environment precautions

ANS: A A patient with Clostridium difficile should be on contact precautions, not droplet; therefore, the nurse will see this patient first to correct the precautions. All the rest are on correct precautions. Patients with tuberculosis belong in airborne precautions; patients with MRSA infection belong in contact precautions; and patients with lung transplants belong in protective environment precautions.

Which activity will cause the nurse to monitor for equipment-related accidents? a. Uses a patient-controlled analgesic pump b. Uses a computer-based documentation record c. Uses a measuring device that measures urine d. Uses a manual medication-dispensing device

ANS: A Accidents that are equipment related result from the malfunction, disrepair, or misuse of equipment or from an electrical hazard. To avoid rapid infusion of IV fluids, all general-use and patient-controlled analgesic pumps need to have free-flow protection devices. Measuring devices used by the nurse to measure urine, computer documentation, and manual dispensing devices can break or malfunction but are not used directly on a patient and are considered procedure-related accidents.

A nurse is teaching a patient about meridians. Which technique is the nurse preparing the patient to receive? a. Acupuncture b. Naturopathic c. Latin American traditional healing d. Native American traditional healing

ANS: A Acupuncture regulates or realigns the vital energy (qi), which flows like a river through the body in channels that form a system of 20 pathways called meridians. Naturopathic therapeutics include herbal medicine, nutritional supplementation, physical medicine, homeopathy, lifestyle counseling, and mind-body therapies with an orientation toward assisting the person's internal capacity for self-healing (vitalism). Tribal traditions are individualistic, but similarities across traditions include the use of sweating and purging, herbal remedies, and ceremonies in which a shaman (a spiritual healer) makes contact with spirits to ask their direction in bringing healing to people to promote wholeness and healing. Curanderismo is a Latin American traditional healing system that includes a humoral model for classifying food, activity, drugs, and illnesses and a series of folk illnesses. The goal is to create a balance between the patient and his or her environment, thereby sustaining health.

The surgical mask the perioperative nurse is wearing becomes moist. Which action will the perioperative nurse take next? a. Apply a new mask. b. Reapply the mask after it air-dries. c. Change the mask when relieved by next shift. d. Do not change the mask if the nurse is comfortable.

ANS: A After the mask is worn for several hours, it can become moist. The mask should be changed as soon as possible because moisture does not provide a barrier to microorganisms and is ineffective. Waiting to change the mask, air-drying it, or wearing it because it is comfortable does not support the principles of infection control.

A teen with an anxiety disorder is referred for biofeedback because the parents do not want their child to take anxiolytics. Which statement from the teen indicates successful learning? a. "Biofeedback will help me with my thoughts and physiological responses to stress." b. "Biofeedback will direct my energies in an intentional way when stressed." c. "Biofeedback will allow me to manipulate my stressed out joints." d. "Biofeedback will let me assess and redirect my energy fields."

ANS: A By using electromechanical instruments, a person can receive information or feedback on his or her stress level. Having this knowledge allows the patient to develop awareness and voluntary control over his or her physiological symptoms. Biofeedback does not address energy fields; healing touch, reiki, and therapeutic touch are energy fields. Directing energies is therapeutic touch. Manipulation of body alignment and joints is done by a chiropractor.

The nurse is caring for a patient who has cultured positive for Clostridium difficile. Which action will the nurse take next? a. Instruct assistive personnel to use soap and water rather than sanitizer. b. Wear an N95 respirator when entering the patient room. c. Place the patient on droplet precautions. d. Teach the patient cough etiquette.

ANS: A Clostridium difficile is a spore-forming organism that can be transmitted through direct and indirect patient contact. Because Clostridium difficile is a spore-forming organism, hand sanitizer is not effective in preventing its transmission. Hands must be washed with soap and water to prevent transmission. This organism is not transmitted via the droplet route; therefore, droplet precautions are not needed. An N95 respirator is used primarily for patients with airborne illness, especially tuberculosis. While all patients should be taught cough etiquette, this action is not specifically related to the patient having Clostridium difficile.

The nurse is observing a family member changing a dressing for a patient in the home health environment. Which observation indicates the family member has a correct understanding of how to manage contaminated dressings? a. The family member places the used dressings in a plastic bag. b. The family member saves part of the dressing because it is clean. c. The family member removes gloves and gathers items for disposal. d. The family member wraps the used dressing in toilet tissue before placing in trash.

ANS: A Contaminated dressings and other infectious, disposable items should be placed in impervious plastic or brown paper bags and then disposed of properly in garbage containers. Gloves should be worn during this process. Parts of the dressing should not be saved, even though they may seem clean, because microbes may be present.

The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. The nurse completes the health history. Which priority concern will require collaboration with social services to address the patient's health care needs? a. The electricity was turned off 3 days ago. b. The water comes from the county water supply. c. A son and family recently moved into the home. d. This home is not furnished with a microwave oven.

ANS: A Electricity is needed for refrigeration of food, and lack of electricity could have contributed to the nausea, vomiting, and diarrhea due to food poisoning. This discussion about the patient's electrical needs can be referred to social services. Foods that are inadequately prepared or stored or subject to unsanitary conditions increase the patient's risk for infections and food poisoning, and an assessment should include storage practices. The water supply, the increased number of individuals in the home, and not having a microwave may or may not be concerns but do not pertain to the current health care needs of this patient.

A nurse is teaching a community group of school-aged parents about safety. Which safety item is most important for the nurse to include in the teaching session? a. Proper fit of a bicycle helmet b. Proper fit of soccer shin guards c. Proper fit of swimming goggles d. Proper fit of baseball sliding shorts

ANS: A Head injuries are a major cause of death, with bicycle accidents being one of the major causes of such injuries. Proper fit of the helmet helps to decrease head injuries resulting from these bicycle accidents. Goggles, shin guards, and sliding shorts are important sports safety equipment and should fit properly, but they do not protect from this leading cause of death.

A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next? a. Remove the restraint. b. Place a blanket over the feet. c. Immediately do a complete head-to-toe neurologic assessment. d. Take the patient's blood pressure, pulse, temperature, and respiratory rate.

ANS: A If the patient has altered neurovascular status of an extremity such as cyanosis, pallor, and coldness of skin or complains of tingling, pain, or numbness, remove the restraint immediately and notify the health care provider. Light blue is cyanosis, indicating the restraints are too tight, not that the patient is cold and needs a blanket. A complete head-to-toe neurological assessment is not needed at this time. The nurse can take vital signs after the restraint is removed.

The nurse is presenting an educational session on safety for parents of adolescents. Which information will the nurse include in the teaching session? a. Increased aggressiveness and blood spots on clothing may indicate substance abuse. b. Increased aggressiveness is an environmental clue that may indicate an adolescent is abusing. c. Adolescents need information about the effects of uncoordination on accidents. d. Adolescents need to be reminded to use seat belts primarily on long trips.

ANS: A Increased aggressiveness (psychosocial clue) and blood spots on clothing (environmental clue) may indicate substance abuse. School-age children are often uncoordinated. Seat belts should be used all the time. In fact, teens have the lowest rate of seat belt use.

The nurse and a new nurse in orientation are caring for a patient with pneumonia. Which statement by the new nurse will indicate a correct understanding of this condition? a. "An infectious disease like pneumonia may not pose a risk to others." b. "We need to isolate the patient in a private negative-pressure room." c. "Clinical signs and symptoms are not present in pneumonia." d. "The patient will not be able to return home."

ANS: A Infections are infectious and/or communicable. Infectious diseases may not pose a risk for transmission to others, although they are serious for the patient. Pneumonia is not a communicable disease—a disease that is transmitted directly from one individual to the next, so there is no need for isolation. A private negative-air pressure room is used for tuberculosis, not pneumonia. Clinical signs and symptoms are present in pneumonia. Frequently, patients with pneumonia do return home unless there are extenuating circumstances.

The nurse is discussing about threats to adult safety with a college group. Which statement by a group member indicates understanding of the topic? a. "Smoking even at parties is not good for my body." b. "Our campus is safe; we leave our dorms unlocked all the time." c. "As long as I have only two drinks, I can still be the designated driver." d. "I am young, so I can work nights and go to school with 2 hours' sleep."

ANS: A Lifestyle choices frequently affect adult safety. Smoking conveys great risk for pulmonary and cardiovascular disease. It is prudent to secure belongings. When an individual has been determined to be the designated driver, that individual does not consume alcohol, beer, or wine. Sleep is important no matter the age of the individual and is important for rest and integration of learning.

A patient asks the nurse for a nonmedical approach for excessive worry and work stress. Which therapy should the nurse recommend? a. Meditation b. Acupuncture c. Ayurvedic herbs d. Chiropractic care

ANS: A Meditation is indicated for stress-related illness and is a nonmedical approach. In addition, meditation increases productivity, improves mood, increases sense of identity, and lowers irritability. Acupuncture, ayurvedic, and chiropractic are all medical approaches. The use of ayurvedic herbs has been available for centuries to treat illness and is a type of whole medical system. Acupuncture focuses on redirecting vital energy (qi) in the body's meridian energy lines to influence deeper internal organs. Chiropractic therapy involves manipulation of the spinal column and includes physiotherapy and diet therapy.

The nurse enters the patient's room and notices a small fire in the headlight above the patient's bed. In which order will the nurse perform the steps, beginning with the first one? 1. Pull the alarm. 2. Remove the patient. 3. Use the fire extinguisher. 4. Close doors and windows. a. 2, 1, 4, 3 b. 1, 2, 4, 3 c. 1, 2, 3, 4 d. 2, 1, 3, 4

ANS: A Nurses use the mnemonic RACE to set priorities in case of fire. The steps are as follows: Rescue and remove all patients in immediate danger; Activate the alarm; Confine the fire by closing doors and windows; and Extinguish the fire using an appropriate extinguisher.

A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens? a. Wash hands b. Wash wound c. Wear gloves d. Wear eye protection

ANS: A One of the most effective methods for limiting the transmission of pathogens is the medically aseptic practice of hand hygiene. The most common means of transmission of pathogens is by the hands. While washing the wound is needed, the best method to prevent transmission is hand hygiene. Wearing gloves and possibly eye protection help protect the nurse, but handwashing is best for limiting the transmission of pathogens.

A home health nurse is assessing a family's home after the birth of an infant. A toddler also lives in the home. Which finding will cause the nurse to follow up? a. Plastic grocery bags are neatly stored under the counter. b. Electric outlets are covered in all rooms. c. No bumper pads are in the crib. d. Crib slats are 5 cm apart.

ANS: A Plastic grocery bags increase the risk for suffocation. The nurse will follow up with instructions to remove or keep locked or out of reach. All the rest are correct and do not require follow-up. Electrical outlets should be covered to reduce electrical shock. Bumper pads are not used in the crib to prevent suffocation, strangulation, or entrapment. Crib slats should be less than 6 cm apart.

The group leader is overheard saying to the gathering of patients, "Focus on your breathing once again .... Notice how it is regular .... Now focus on your left arm .... Notice how relaxed your left arm feels .... Notice the relaxation going down the left arm to the hand." A patient asks the nurse what the group is doing. What is the nurse's bestresponse? a. It is progressive relaxation training. b. It is group biofeedback. c. It is guided imagery. d. It is meditation.

ANS: A Progressive relaxation training teaches the individual how to effectively rest and reduce tension in the body. The technique used in this scenario involves the use of slow, deep abdominal breathing while tightening and relaxing an ordered succession of muscle groups. Although meditation does include abdominal breathing, along with guided imagery and biofeedback, it does not include tightening and relaxing of muscle groups in an ordered succession.

The nurse on the surgical team and the surgeon have completed a surgery. After donning gloves, gathering instruments, and placing in the transport carrier, what is the next step in handling the instruments used during the procedure? a. Sending to central sterile for cleaning and sterilization b. Sending to central sterile for cleaning and disinfection c. Sending to central sterile for cleaning and boiling d. Sending to central sterile for cleaning

ANS: A Surgical instruments need to be cleaned and sterilized. Disinfecting, boiling, or cleaning is not utilized on critical items that will be reused on patients in the hospital environment. Items that are used on sterile tissue or in the vascular system present a high risk of infection if they become contaminated with bacteria.

A patient presents with pneumonia. Which priority intervention should be included in the plan of care for this patient? a. Observe the patient for decreased activity tolerance. b. Assume the patient is in pain and treat accordingly. c. Provide the patient ice chips as requested. d. Maintain the room temperature at 65° F.

ANS: A Systemic infection, like pneumonia, causes more generalized symptoms than local infection. This type of infection can result in fever, fatigue, nausea and vomiting, and malaise; be alert for changes in the patient's level of activity and responsiveness. Nurses do not assume but assess and communicate with the patient about pain. While providing the patient with ice chips may be appropriate, it is not a priority and there is no reason for the patient to be limited to ice. Maintaining the room temperature at 65° F is too cold.

The nurse is caring for a patient who becomes nauseated and vomits without warning. The nurse has contaminated hands. Which action is best for the nurse to take next? a. Wash hands with an antimicrobial soap and water. b. Clean hands with wipes from the bedside table. c. Use an alcohol-based waterless hand gel. d. Wipe hands with a dry paper towel.

ANS: A The Centers for Disease Control and Prevention (CDC) recommends that when hands are visibly soiled, one should wash with a non-antimicrobial soap or with antimicrobial soap. Cleaning hands with wipes or using waterless hand gel does not meet this standard. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands. Wiping hands with a dry paper towel will occur after the nurse has washed both hands.

The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes affecting safety. Which question would be most important for the nurse to ask this group? a. "Are you able to hear the tornado sirens in your area?" b. "Are you able to read your favorite book?" c. "Are you able to taste spices like before?" d. "Are you able to open a jar of pickles?"

ANS: A The ability to hear safety alerts and seek shelter is imperative to life safety. Decreased hearing acuity alters the ability to hear emergency vehicle sirens. Natural disasters such as floods, tsunamis, hurricanes, tornadoes, and wildfires are major causes of death and injury. Although age-related changes may cause a decrease in sight that affects reading, and although tasting is impaired and opening jars as arthritis sets in are important to patients and to those caring for them, being able to hear safety alerts is the most important.

The nurse is caring for a patient in the hospital. The nurse observes the nursing assistive personnel (NAP) turning off the handle faucet with bare hands. Which professional practice principle supports the need for follow-up with the NAP? a. The nurse is responsible for providing a safe environment for the patient. b. Different scopes of practice allow modification of procedures. c. Allowing the water to run is a waste of resources and money. d. This is a key step in the procedure for washing hands.

ANS: A The nurse is responsible for providing a safe environment for the patient. The effectiveness of infection control practices depends on conscientiousness and consistency in using effective aseptic technique by all health care providers. After washing hands, turn off a handle faucet with a dry paper towel, and avoid touching the handles with your hands to assist in preventing the transfer of microorganisms. Wet towels and hands allow the transfer of pathogens from faucet to hands. The principles and procedures for washing hands are universal and apply to all members of health care teams. Being resourceful and aware of the cost of health care is important, but taking shortcuts that may endanger an individual's health is not a prudent practice.

A confused patient is restless and continues to try to remove the oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient? a. Risk for injury: Check on patient every 15 minutes. b. Risk for suffocation: Place "Oxygen in Use" sign on door. c. Disturbed body image: Encourage patient to express concerns about body. d. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter.

ANS: A The priority nursing diagnosis is Risk for injury. This patient could cause harm to self by interrupting the oxygen therapy or by damaging the urethra by pulling the urinary catheter out. Before restraining a patient, it is important to implement and exhaust alternatives to restraint. Alternatives can include more frequent observations. This patient may have deficient knowledge; educating the patient about treatments could be considered as an alternative to restraints. However, the nursing diagnosis of highest priority is risk for injury. This scenario does not indicate that the patient has a disturbed body image or that the patient is at risk for suffocation.

The nurse is dressed and is preparing to care for a patient in the perioperative area. The nurse has scrubbed hands and has donned a sterile gown and gloves. Which action will indicate a break in sterile technique? a. Touching clean protective eyewear b. Standing with hands above waist area c. Accepting sterile supplies from the surgeon d. Staying with the sterile table once it is open

ANS: A Touching nonsterile (clean) protective eyewear once gowned and gloved with sterile gown and gloves would indicate a break in sterile technique. Sterile objects remain sterile only when touched by another sterile object. Standing with hands folded on the chest is common practice and prevents arms and hands from touching unsterile objects. Accepting sterile supplies from the surgeon who has opened them with the appropriate technique is acceptable. Staying with a sterile table once opened is a common practice to ascertain that no one or nothing has contaminated the table.

The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take? a. Assess the patient. b. Gather restraint supplies. c. Try alternatives to restraint. d. Call the health care provider for a restraint order.

ANS: A When a patient becomes suddenly confused, the priority is to assess the patient, to identify the reason for change in behavior, and to try to eliminate the cause. If interventions and alternatives are exhausted, the nurse working with the health care provider may determine the need for restraints.

The nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym. Which questions will the nurse ask the patient? (Select all that apply.) a. Where did you fall? b. What time did the fall occur? c. What were you doing when you fell? d. What types of injuries occurred after the fall? e. Did you obtain an electronic safety alert device after the fall? f. What are your medical problems that may have caused the fall?

ANS: A, B, C, D Assess previous falls; using the acronym SPLATT: Symptoms at time of fall Previous fall Location of fall Activity at time of fall Time of fall Trauma after fall Medical diagnoses and an alert device are not components of SPLATT.

The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take? (Select all that apply.) a. Close all doors. b. Note evacuation routes. c. Note oxygen shut-offs. d. Move bedridden patients in their bed. e. Wait until the fire department arrives to act. f. Use type B fire extinguishers for electrical fires.

ANS: A, B, C, D Closing all doors helps to contain smoke and fire. Noting the evacuation routes and oxygen shut-offs is important in case evacuation is needed. You will move bedridden patients from the scene of a fire by a stretcher, bed, or wheelchair. The nurse cannot wait until the fire department arrives to act. Type C fire extinguishers are used for electrical fires; type B is used for flammable liquids.

The nurse is assessing a new patient admitted to home health. Which questions will be most appropriate for the nurse to ask to determine the risk of infection? (Select all that apply.) a. "Can you explain the risk for infection in your home?" b. "Have you traveled outside of the United States?" c. "Will you demonstrate how to wash your hands?" d. "What are the signs and symptoms of infection?" e. "Are you able to walk to the mailbox?" f. "Who runs errands for you?"

ANS: A, B, C, D In the home setting, the objective is that the patient and/or family will utilize proper infection control techniques. Asking the patient and family about handwashing, risk of infection, recent travel, and signs and symptoms of infection is important in evaluating the patient's knowledge based on infection control strategies. Activity assessment is important for evaluation of the overall status of the patient, and knowing who runs errands gives you information on who is helping to meet the needs of the patient, but neither of these relates to decreasing the risk of infection.

The nurse and the student nurse are caring for two different patients on the medical-surgical unit. One patient is in airborne precautions, and one is in contact precautions. The nurse explains to the student different interventions for care. Which information will the nurse include in the teaching session? (Select all that apply.) a. Dispose of supplies to prevent the spread of microorganisms. b. Wash hands before entering and leaving both of the patients' rooms. c. Be consistent in nursing interventions since there is only one difference in the precautions. d. Apply the knowledge the nurse has of the disease process to prevent the spread of microorganisms. e. Have patients in airborne precautions wear a mask during transportation to other departments. f. Check the working order of the negative-pressure room for the airborne precaution patient on admission and discharge.

ANS: A, B, D, E Washing hands, properly disposing of supplies, applying knowledge of the disease process, and having patients in airborne precautions wear a mask during transfer are all principles to follow when caring for patients in isolation. Multiple differences are evident among these types of isolation, including the type of room used for the patient and what the nurse wears while caring for the patient. It is important to check the working order of a negative-pressure room before admitting a patient to the room, each shift the patient is in the room, and if and when the device alarms. Checking the working order of the negative-pressure rooms at discharge is not necessary.

The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. Which items will the nurse need to care for this patient? (Select all that apply.) a. Private room b. Negative-pressure airflow in room c. Surgical mask, gown, gloves, eyewear d. N95 respirator, gown, gloves, eyewear e. Communication signs for droplet precautions f. Communication signs for airborne precautions

ANS: A, B, D, F Caring for this patient requires a private room, negative-pressure airflow in room, and wearing an N95 respirator that has been fit-tested, gloves, gown, and eyewear. Tuberculosis is a disease that is transmitted by droplets that remain in the air for long periods of time, requiring airborne precautions. This patient will not be in droplet precautions and instead requires airborne precaution signs. This type of patient requires more than the average surgical mask for protection.

A home health nurse is assessing the home for fire safety. Which information from the family will cause the nurse to intervene? (Select all that apply.) a. Smoking in bed helps me relax and fall asleep. b. We never leave candles burning when we are gone. c. We use the same space heater my grandparents used. d. We use the RACE method when using the fire extinguisher. e. There is a fire extinguisher in the kitchen and garage workshop.

ANS: A, C, D Incorrect information will cause the nurse to intervene. Accidental home fires typically result from smoking in bed. Advise families to only purchase newer model space heaters that have all of the current safety features. The PASS method is used for fire extinguishers. All the rest are correct and do not require follow-up. Candles should not be left burning when no one is home. Keep a fire extinguisher in the kitchen, near the furnace, and in the garage.

An older-adult patient is using a wheelchair to attend a physical therapy session. Which action by the nurse indicates safe transport of the patient? a. Positions patient's buttocks close to the front of wheelchair seat b. Backs wheelchair into elevator, leading with large rear wheels first c. Places locked wheelchair on same side of bed as patient's weaker side d. Unlocks wheelchair for easy maneuverability when patient is transferring

ANS: B A correct action when using a wheelchair is to back wheelchair into an elevator, leading with large rear wheels first. A patient's buttocks should be well back into the seat. A locked wheelchair should be placed on a patient's strong or unaffected side. Brakes should be securely locked when a patient is transferring.

A home health nurse is teaching a family to prevent electrical shock. Which information will the nurse include in the teaching session? a. Run wires under the carpet. b. Disconnect items before cleaning. c. Grasp the cord when unplugging items. d. Use masking tape to secure cords to the floor.

ANS: B A guideline to prevent electrical shock is to disconnect items before cleaning. Do not run wires under carpeting. Grasp the plug, not the cord, when unplugging items. Use electrical tape to secure the cord to the floor, preferably against baseboards.

The nurse is providing an education session to an adult community group about the effects of smoking on infection. Which information is most important for the nurse to include in the educational session? a. Smoke from tobacco products clings to your clothing and hair. b. Smoking affects the cilia lining the upper airways in the lungs. c. Smoking can affect the color of the patient's fingernails. d. Smoking tobacco products can be very expensive.

ANS: B A normal defense mechanism against infection in the respiratory tract is the cilia lining the upper airways of the lungs and normal mucus. When a patient inhales a microbe, the cilia and mucus trap the microbe and sweep them up and out to be expectorated or swallowed. Smoking may alter this defense mechanism and increase the patient's potential for infection. Smoking can be expensive, the smell does cling to hair and clothing, and the tar within the smoke can alter the color of a patient's nails. This information can be included in the education but does not constitute the most important point.

The patient has been diagnosed with a respiratory illness and reports shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. At which temperature range will the nurse set the thermostat? a. 60° to 64° F b. 65° to 75° F c. 15° to 17° C d. 25° to 28° C

ANS: B A person's comfort zone is usually between 18.3° and 23.9° C (65° and 75° F). The other ranges are too low or too high and do not reflect the average person's comfort zone.

The nurse has placed a yellow armband on a 70-year-old patient. Which observation by the nurse will indicate the patient has an understanding of this action? a. The patient removes the armband to bathe. b. The patient wears the red nonslip footwear. c. The patient insists on taking a "water" pill in the evening. d. The patient who is allergic to penicillin asks the name of a new medicine.

ANS: B A yellow armband is an alert for high risk of falls. Red nonslip footwear helps to grip the floor and decreases the chance of falling. The communication armband should stay in place and should not be removed, so that all members of the interdisciplinary team have the information about the high risk for falls. A red armband indicates an allergy. Give diuretics ("water" pill) in the morning to decrease risk of falls during the night—when most falls occur.

The nurse is caring for a patient who has a bloodborne pathogen. The nurse splashes blood above the glove to intact skin while discontinuing an intravenous (IV) infusion. Which step(s) will the nurse take next? a. Obtain an alcohol swab, remove the blood with an alcohol swab, and continue care. b. Immediately wash the site with soap and running water, and seek guidance from the manager. c. Do nothing; accidentally getting splashed with blood happens frequently and is part of the job. d. Delay washing of the site until the nurse is finished providing care to the patient.

ANS: B After getting splashed with blood from a patient who has a known bloodborne pathogen, it is important to cleanse the site immediately and thoroughly with soap and running water and notify the manager for guidance on next steps in the process. Removing the blood with an alcohol swab, delaying washing, and doing nothing because the splash was to intact skin could possibly spread the blood within the room and could spread the infection. Contain contamination immediately to prevent contact spread.

The patient has contracted a urinary tract infection (UTI) while in the hospital. Which action will most likely increase the risk of a patient contracting a UTI? a. Reusing the patient's graduated receptacle to empty the drainage bag. b. Allowing the drainage bag port to touch the graduated receptacle. c. Emptying the urinary drainage bag at least once a shift. d. Irrigating the catheter infrequently.

ANS: B Allowing the urinary drainage bag port to touch contaminated items (graduated receptacle) may introduce bacteria into the urinary system and contribute to a urinary tract infection. The urinary drainage bag should be emptied at least once a shift. Patients should have their own receptacle for measurement to prevent cross-contamination. Repeated catheter irrigations increase the chance so irrigating infrequently will be beneficial in reducing the risk.

The infection control nurse is reviewing data for the medical-surgical unit. The nurse notices an increase in postoperative infections from Aspergillus. Which type of health care-associated infection will the nurse report? a. Vector b. Exogenous c. Endogenous d. Suprainfection

ANS: B An exogenous infection comes from microorganisms found outside the individual such as Salmonella, Clostridiumtetani, and Aspergillus. They do not exist as normal floras. A vector transmits microorganisms and is usually a type of insect or organism. Endogenous infection occurs when part of the patient's flora becomes altered and an overgrowth results (e.g., staphylococci, enterococci, yeasts, and streptococci). This often happens when a patient receives broad-spectrum antibiotics that alter the normal floras. A suprainfection develops when broad-spectrum antibiotics eliminate a wide range of normal flora organisms, not just those causing infection.

The nurse is changing linens for a postoperative patient and feels a prick in the left hand. A nonactivated safe needle is noted in the linens. For which condition is the nurse most at risk? a. Diphtheria b. Hepatitis B c. Clostridium difficile d. Methicillin-resistant Staphylococcus aureus

ANS: B Bloodborne pathogens such as those associated with hepatitis B and C are most commonly transmitted by contaminated needles. Clostridium difficile and MRSA are spread by contact. Diphtheria is spread by droplets when one is within 3 feet of the patient.

A nurse is teaching about the therapy that is more effective in treating physical ailments than in preventing disease or managing chronic illness. Which therapy is the nurse describing? a. Complementary b. Allopathic c. Alternative d. Mind-body

ANS: B Despite the success of allopathic or biomedicine (conventional Western medicine), many conditions such as chronic back and neck pain, arthritis, gastrointestinal problems, allergies, headache, and anxiety continue to be difficult to treat. Complementary, alternative, and mind-body types of medicines can be used in tandem with allopathic medicines but are distinctly different.

Which process will be required after exposure of a nurse to blood by a cut from a used scalpel in the operative area? a. Placing the scalpel in a needle safe container b. Testing the patient and offering treatment to the nurse c. Removing sterile gloves and disposing of in kick bucket d. Providing a medical evaluation of the nurse to the manager

ANS: B Follow-up for risk of infection begins with patient testing. Patients should be tested for HIV and hepatitis B and C. Testing of the nurse is dependent on the results of patient testing; if the patient is positive for one of these infections, the nurse will be started on testing and treatment. Removing sterile gloves and placing sharps in appropriate containers are always part of the perioperative process and are not the process for postexposure. A confidential medical evaluation is provided to the nurse, not the manager.

The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse ispriority? a. Monitor for specific symptoms. b. Manage all patients using standard precautions. c. Transport patients quickly and efficiently through the elevators. d. Prepare for post-traumatic stress associated with this bioterrorism attack.

ANS: B Manage all patients with suspected or confirmed bioterrorism-related illnesses using standard precautions. For certain diseases, additional precautions may be necessary. The early signs of a bioterrorism-related illness often include nonspecific symptoms (e.g., nausea, vomiting, diarrhea, skin rash, fever, confusion) that may persist for several days before the onset of more severe disease. Limit the transport and movement of patients to movement that is essential for treatment and care. Psychosocial concerns (post-traumatic stress) are important but are not the first priority at this moment.

The nurse is admitting a patient with an infectious disease process. Which question will be most appropriate for a nurse to ask about the patient's susceptibility to this infectious process? a. "Do you have a spouse?" b. "Do you have a chronic disease?" c. "Do you have any children living in the home?" d. "Do you have any religious beliefs that will influence your care?"

ANS: B Multiple factors influence a patient's susceptibility to infection. Patients with chronic diseases such as diabetes mellitus and multiple sclerosis are also more susceptible to infection because of general debilitation and nutritional impairment. Other factors include age, nutritional status, trauma, and smoking. The other questions are part of an admission assessment process but are not pertinent to the infectious disease process.

During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls? a. The patient is oriented. b. The patient takes a hypnotic. c. The patient walks 2 miles a day. d. The patient recently became widowed.

ANS: B Numerous factors increase the risk of falls, including a history of falling and the effects of various medications such as anticonvulsants, hypnotics, sedatives, and certain analgesics. Being oriented will decrease risk for falls while disorientation will increase the risk of falling. Walking has many benefits, including increasing strength, which would be beneficial in decreasing risk. Becoming widowed would increase stress and may affect concentration but is not a great risk.

The home health nurse is teaching a patient and family about hand hygiene in the home. Which situation will cause the nurse to emphasize washing hands before and after? a. Shaking hands b. Performing treatments c. Opening the refrigerator d. Working on a computer

ANS: B Patients and family members should perform hand hygiene before and after treatments and when coming in contact with body fluids. Shaking hands does not require washing of hands before and after. Washing hands before and after opening the refrigerator and using the computer is not required

The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the need for a restraint? a. The patient refuses to call for help to go to the bathroom. b. The patient continues to remove the nasogastric tube. c. The patient gets confused regarding the time at night. d. The patient does not sleep and continues to ask for items.

ANS: B Patients who are confused, disoriented, and wander or repeatedly fall or try to remove medical devices (e.g., oxygen equipment, IV lines, or dressings) often require the temporary use of restraints to keep them safe. Restraints can be used to prevent interruption of therapy such as traction, IV infusions, NG tube feeding, or Foley catheterization. Refusing to call for help, although unsafe, is not a reason for restraint. Getting confused at night regarding the time or not sleeping and bothering the staff to ask for items is not a reason for restraint.

The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which action should the nurse take next? a. Do nothing, no harm has occurred. b. Notify the health care provider. c. Complete an incident report. d. Assess the patient.

ANS: B Report immediately to physician or health care provider if the patient sustains a fall or an injury. The nurse must provide safe care, and doing nothing is not safe care. The scenario indicates the nurse has already assessed the patient. After the patient has stabilized, completing an incident report would be the last step in the process.

The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event? a. No blood incompatibility occurs with a blood transfusion. b. A surgical sponge is left in the patient's incision. c. Pulmonary embolism after lung surgery d. Stage II pressure ulcer

ANS: B The Centers for Medicare and Medicaid Services names select serious reportable events as Never Events (i.e., adverse events that should never occur in a health care setting). A surgical sponge left in a patient's incision is a Never Event. No blood incompatibility reaction is safe practice. Pulmonary embolism after certain orthopedic procedures is like a total knee and hip replacement. Stage III and IV pressure ulcers are Never Events.

The nurse is assessing a patient for lead poisoning. Which patient is the nurse most likely assessing? a. Young infant b. Toddler c. Preschooler d. Adolescent

ANS: B The incidence of lead poisoning is highest in late infancy and toddlerhood. Children at this stage explore the environment and, because of their increased level of oral activity, put objects in their mouths. Young infant is too young. A preschooler and an adolescent are too old.

Which patient will the nurse see first? a. A 56-year-old patient with oxygen with a lighter on the bedside table b. A 56-year-old patient with oxygen using an electric razor for grooming c. A 1-month-old infant looking at a shiny, round battery just out of arm's reach d. A 1-month-old infant with a pacifier that has no string around the baby's neck

ANS: B The nurse will see the patient shaving with an electric razor first as this is an actual problem. Do not use oxygen around electrical equipment or flammable products. A lighter on the bedside table and a shiny, round battery are potential problems, not actual. Plus, it would be hard, almost impossible, for a 1 month old to actually grab the battery when it is out of arm's reach. A baby should use a pacifier without strings.

The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse's assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient's temperature is 100.5° F, and the WBC is 10,500/mm3. Which action should the nurse take first? a. Plan to change the surgical dressing during the shift. b. Utilize SBAR to notify the primary health care provider. c. Reevaluate the temperature and white blood cell count in 4 hours. d. Check to see what solution was used for skin preparation in surgery.

ANS: B The nursing assessment indicates signs and symptoms of infection, requiring the primary health care provider to be notified of the patient's needs. SBAR—Situation, Background, Assessment, and Recommendation—can be utilized to organize thoughts and data and to provide a thorough explanation of the patient's current status. The reevaluation of temperature is a good choice, but it will take longer than 4 hours to make a change in the white blood cells. Changing the dressing may be a need during the shift but is not a first priority. Checking to see about the skin preparation used 2 days ago may or may not be useful information at this time.

The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient's application of the devices and finds that they have been put on upside down. Which nursing diagnosis will the nurse add to the patient's plan of care? a. Risk for falls b. Deficient knowledge c. Risk for suffocation d. Impaired physical mobility

ANS: B The patient has a knowledge need and requires instruction regarding the device and its purpose and procedure. The nurse will intervene by teaching the patient about the sequential compression device and instructing the patient to call for assistance when getting up to go to the bathroom in the future, so that the nurse may assist with removal and proper reapplication. No data support a risk for falls, impaired physical mobility, or suffocation.

A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately? a. Respiratory rate b. Temperature c. Apical pulse d. Blood pressure

ANS: B The temperature indicates the patient is experiencing hypothermia. Homeless individuals are more at risk for hypothermia. While all the vital signs are low, the most critical vital sign at this time is the temperature.

Which nursing action will most likely increase a patient's risk for developing a health care-associated infection? a. Uses surgical aseptic technique to suction an airway b. Uses a clean technique for inserting a urinary catheter c. Uses a cleaning stroke from the urinary meatus toward the rectum d. Uses a sterile bottled solution more than once within a 24-hour period

ANS: B Using clean technique (medical asepsis) to insert a urinary catheter would place the patient at risk for a health care-associated infection. Urinary catheters need to be inserted using sterile technique, which is also referred to as surgical asepsis. Surgical aseptic technique (also called sterile technique) should be used when suctioning an airway because it is considered a sterile body cavity. Washing from clean to dirty (urinary meatus toward rectum) is correct for decreasing infection risk. Bottled solutions may be used repeatedly during a 24-hour period; however, special care is needed to ensure that the solution in the bottle remains sterile. After 24 hours, the solution should be discarded.

The circulating nurse in the operating room is observing the surgical technologist while applying a sterile gown and gloves to care for a patient having an appendectomy. Which behaviors indicate to the nurse that the procedure by the surgical technologist is correct? (Select all that apply.) a. Ties the back of own gown b. Touches only the inside of gown c. Slips arms into arm holes simultaneously d. Extended fingers fully into both of the gloves e. Uses hands covered by sleeves to open gloves f. Applies surgical cap and face mask in the operating suite

ANS: B, C, D, E To maintain sterility, the surgical technologist (ST) touches the inside of the gown that will be against the body. Arms are slipped simultaneously into the gown to prevent contamination. Using the sleeves covering the hands maintains the principle of sterile only touching sterile to open gloves. Extending the fingers fully into both gloves ensures that the ST has full dexterity while using the sterile gloved hand. Surgical cap, face mask, and eye wear are applied before entering the surgical area and completing the surgical scrub. Reaching behind to tie the back of the gown will contaminate the sterile area of the gown.

The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which information will the nurse include in the teaching session? (Select all that apply.) a. Water outdoor plants with a nozzle and hose. b. Walk to the mailbox in the summer. c. Encourage yearly eye examinations. d. Use bathtubs without safety strips. e. Keep pathways clutter free.

ANS: B, C, E Walking to the mailbox in summer provides exercise when pathways are not icy and slick. Encourage annual vision and hearing examinations. Pathways that are clutter free reduce fall risk. Using a hose to water plants and using tubs without safety strips are all items the patient should avoid to help in the prevention of falls in the home.

The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care? (Select all that apply.) a. One family member has gone to lunch. b. Patient is placed in bilateral wrist restraints at 0815. c. Bilateral radial pulses present, 2+, hands warm to touch d. Straps with quick-release buckle attached to bed side rails e. Attempts to distract the patient with television are unsuccessful. f. Released from restraints, active range-of-motion exercises completed

ANS: B, C, E, F Proper documentation, including the behaviors that necessitated the application of restraints, the procedure used in restraining, the condition of the body part restrained (e.g., circulation to hand), and the evaluation of the patient response, is essential. Record nursing interventions, including restraint alternatives tried, in nurses' notes. Record purpose for restraint, type and location of restraint used, time applied and discontinued, times restraint was released, and routine observations (e.g., skin color, pulses, sensation, vital signs, and behavior) in nurses' notes and flow sheets. Straps are not attached to side rails. Comments about the activities of one family member are not necessarily required in nursing documentation of restraints.

A patient requires restraints after alternatives are not successful. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for safe care? (Select all that apply.) a. Health care provider orders restraints prn (as needed). b. Health care provider writes the type and location of the restraint. c. Health care provider renews orders for restraints every 24 hours. d. Health care provider performs a face-to-face assessment prior to the order. e. Health care provider specifies the duration and circumstances under which the restraint will be used.

ANS: B, D, E A physician's/health care provider's order is required, based on a face-to-face assessment of the patient. The order must be current, state the type and location of restraint, and specify the duration and circumstances under which it will be used. These orders need to be renewed within a specific time frame according to the policy of the agency. In hospital settings each original restraint order and renewal is limited to 8 hours for adults, 2 hours for ages 9 through 17, and 1 hour for children under age 9. Restraints are not to be ordered prn (as needed).

The nurse is caring for a patient in protective environment. Which actions will the nurse take? (Select all that apply.) a. Wear an N95 respirator when entering the patient's room. b. Maintain airflow rate greater than 12 air exchanges/hr. c. Place in special room with negative-pressure airflow. d. Open drapes during the daytime. e. Listen to the patient's interests. f. Place dried flowers in a plastic vase.

ANS: B, D, E This form of isolation requires a specialized room with positive airflow. The airflow rate is set at greater than 12 air exchanges/hr, and all air is filtered through a HEPA filter. Isolation disrupts normal social relationships with visitors and caregivers. Take the opportunity to listen to a patient's concerns or interests. Open drapes or shades and remove excess supplies and equipment. Patients are not allowed to have dried or fresh flowers or potted plants in these rooms. All health care personnel wear an N95 respirator every time they enter the room for patients, and a private room with negative airflow is required for patients on airborne precautions.

The nurse is preparing to insert a urinary catheter. The nurse is using open gloving to apply the sterile gloves. Which steps will the nurse take? (Select all that apply.) a. While putting on the first glove, touch only the outside surface of the glove. b. With gloved dominant hand, slip fingers underneath second glove cuff. c. Remove outer glove package by tearing the package open. d. Lay glove package on clean flat surface above waistline. e. Glove the dominant hand of the nurse first. f. After second glove is on, interlock hands.

ANS: B, D, E, F Sterile objects held below the waist are considered contaminated. Gloving the dominant hand helps to improve dexterity. Slipping the fingers underneath the second glove cuff helps to keep the gloved fingers sterile. Interlocking fingers ensures a smooth fit over the fingers. Sterile supplies are opened by carefully separating and peeling apart the sides of the package. This prevents the sterile contents from accidentally opening and touching contaminated objects. While putting on the first glove, touching only the outside surface of the glove will contaminate the sterile item; touch only the inside of the glove—the piece that will be against the skin.

The nurse is caring for a patient who is susceptible to infection. Which instruction will the nurse include in an educational session to decrease the risk of infection? a. Teaching the patient about fall prevention b. Teaching the patient to take a temperature c. Teaching the patient to select nutritious foods d. Teaching the patient about the effects of alcohol

ANS: C A patient's nutritional health directly influences susceptibility to infection. A reduction in the intake of protein and other nutrients such as carbohydrates and fats reduces body defenses against infection and impairs wound healing. This is the only teaching point that directly influences risk. Teaching the patient how to take a temperature can help the patient assess if there is a fever, but it is not related to decreasing the individual's risk for infection. Teaching the patient about fall prevention or about the effects of alcohol does not decrease the risk of infection.

A patient asks about the new clinic in town that is staffed by allopathic and complementary practitioners. Which response from the nurse is best? a. It is probably an ayurvedic clinic. b. It is probably a homeopathic clinic. c. It is probably an integrative medical clinic. d. It is probably a naturopathic medical clinic.

ANS: C An integrative medical program allows health care consumers to be treated by a team of providers consisting of both allopathic and complementary practitioners. Several therapies are always considered alternative because they are based on completely different philosophies and life systems from those used by allopathic medicine. Alternative therapies include ayurvedic, homeopathic, and naturopathic.

A female adult patient presents to the clinic with reports of a white discharge and itching in the vaginal area. A nurse is taking a health history. Which question is the priority? a. "When was the last time you visited your primary health care provider?" b. "Has this condition affected your eating habits in any way?" c. "What medications are you currently taking?" d. "Are you able to sleep at night?"

ANS: C Antibiotics and oral contraceptives can disrupt normal flora in the vagina, causing an overgrowth of Candida albicansin that area. It is important to ask the patient about current medications to obtain information that may assist with diagnosis. The body contains normal flora (microorganisms) that live on the surface of skin, saliva, oral mucosa, gastrointestinal tract, and genitourinary tract. The normal flora of the vagina causes vaginal secretions to achieve a low pH, inhibiting the growth of many microorganisms. Visiting the primary health care provider is important for the patient's health maintenance but is not the priority. Learning about the patient's eating and sleeping habits will assist in the plan of care but is not the priority.

The nurse is caring for an adult patient in the clinic who has been evacuated and is a victim of flooding. The nurse teaches the patient about rest, exercise, and eating properly and how to utilize deep breathing and visualization. What is the primary rationale for the nurse's actions related to the teaching? a. Topics taught are standard information taught during health care visits. b. The patient requested this information to teach the extended family members. c. Stress for long periods of time can lead to exhaustion and decreased resistance to infection. d. These techniques will help the patient manage the pain and loss of personal belongings.

ANS: C The body responds to emotional or physical stress by the general adaptation syndrome. If stress extends for long periods of time, this can lead to exhaustion, whereby energy stores are depleted and the body has no defenses against invading organisms. Techniques of deep breathing and visualization may be helpful with pain, but they are not the primary reason. The teachings listed are not all standard interventions taught at every health care visit. There is no data to indicate the patient requested this information for the family.

The nurse is caring for a patient in labor and delivery. When near completing an assessment of the patient's cervix, the electronic infusion device being used on the intravenous (IV) infusion alarms. Which sequence of actions is mostappropriate for the nurse to take? a. Complete the assessment, remove gloves, and silence the alarm. b. Discontinue the assessment, silence the alarm, and assess the intravenous site. c. Complete the assessment, remove gloves, wash hands, and assess the intravenous infusion. d. Discontinue the assessment, remove gloves, use hand gel, and assess the intravenous infusion.

ANS: C Completing the assessment while wearing gloves, removing gloves, washing hands after contact with body fluids, and then assessing the intravenous infusion will assist in the prevention and transfer of any potential organisms to this intravenous line. Completing the assessment, removing gloves, and silencing the alarm leaves out the crucial step of decontaminating and washing the hands. Discontinuing the assessment and assessing the IV leaves out removing the gloves and decontamination, as well as completing the assessment for the patient. Discontinuing the assessment, removing gloves, using hand gel, and assessing the IV is incorrect because upon exposure to body fluids, washing hands is appropriate.

A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals? a. Identifies patient with one identifier before transporting to x-ray department b. Initiates an intravenous (IV) catheter using clean technique on the first try c. Uses medication bar coding when administering medications d. Obtains vital signs to place on a surgical patient's chart

ANS: C One of the National Patient Safety Goals is to use medicines safely. For example, proper preparation and administration of medications, use of patient and medication bar coding, and "smart" intravenous (IV) pumps reduce medication errors. Identifying patients correctly is a national patient safety goal, and two identifiers are needed, not one. Another goal is to prevent infection; starting an IV should be a sterile technique, not a clean technique. While obtaining vital signs is a component of safe care, it does not meet a national patient safety goal.

The nurse is trying to use alternatives rather than restrain a patient. Which finding will cause the nurse to determine the alternative is working? a. The patient continues to get up from the chair at the nurses' station. b. The patient gets restless when the sitter leaves for lunch. c. The patient folds three washcloths over and over. d. The patient apologizes for being "such a bother."

ANS: C Restraint alternatives include more frequent observations, social interaction such as involvement of family during visitation, frequent reorientation, regular exercise, and the introduction of familiar and meaningful stimuli (e.g., involve in hobbies such as knitting or crocheting or looking at family photos) within the environment or folding washcloths. Getting up constantly can be cause for concern. Apologizing is not an alternative to restraints. Getting restless when the sitter leaves indicates the alternative is not working.

The patient and the nurse are discussing Rickettsia rickettsii—Rocky Mountain spotted fever. Which patient statement to the nurse indicates understanding regarding the mode of transmission for this disease? a. "When camping, I will use sunscreen." b. "When camping, I will drink bottled water." c. "When camping, I will wear insect repellent." d. "When camping, I will wash my hands with hand gel."

ANS: C Rocky Mountain spotted fever is caused by bacteria transmitted by the bite of ticks. Wearing a repellent that is designed for repelling ticks, mosquitoes, and other insects can help in preventing transmission of this disease. Drinking plenty of uncontaminated water, wearing sunscreen, and using alcohol-based hand gels for cleaning hands are all important activities to participate in while camping, but they do not contribute to or prevent transmission of this disease.

The nurse is caring for a patient who has just delivered a neonate. The nurse is checking the patient for excessive vaginal drainage. Which precaution will the nurse use? a. Contact b. Droplet c. Standard d. Protective environment

ANS: C Standard precautions apply to contact with blood, body fluid, nonintact skin, and mucous membranes of all patients. Contact precautions apply to individuals with infections that can be transmitted by direct or indirect contact. Protective environment precautions apply to individuals who have undergone transplantations and gene therapy. Droplet precautions focus on diseases that are transmitted by large droplets.

The nurse is caring for a patient in the endoscopy area. The nurse observes the technician performing these tasks. Which observation will require the nurse to intervene? a. Washing hands after removing gloves b. Disinfecting endoscopes in the workroom c. Removing gloves to transfer the endoscope d. Placing the endoscope in a container for transfer

ANS: C Standard precautions are used to prevent and control the spread of infection. Transferring contaminated equipment without the protection of gloves can assist in the spread of microbes to inanimate objects and to the person doing the transfer; therefore, the nurse must intervene. Utilizing gloves, washing hands, covering contaminated supplies during transfer, and disinfecting equipment in the appropriate way in the appropriate places utilize principles of basic medical asepsis and standard precautions and can break the chain of infection.

The nurse is caring for a patient in an intensive care unit who needs a bath. Which priority action will the nurse take to decrease the potential for a health care-associated infection? a. Use local anesthetic on reddened areas. b. Use nonallergenic tape on dressings. c. Use a chlorhexidine wash. d. Use filtered water.

ANS: C The Centers for Disease Control and Prevention (CDC) recommends the use of chlorhexidine (CHG) bathing for patients in intensive care units, patients who are scheduled for surgery, and all patients with invasive central line catheters as part of MRSA reduction efforts. Using local anesthetics, nonallergenic tape, and filtered water does not affect the cause of a health care-associated infection by, for example, decreasing microbial counts like a CHG bath.

A patient describes practicing a complementary and alternative therapy involving breathwork and yoga. The nurse also recommends using energy field therapies. Which techniques did the nurse suggest? a. Prayer and tai chi b. The "zone" and acupressure c. Massage therapy and ayurveda d. Reiki therapy and therapeutic touch

ANS: D Both yoga and breathwork are mind-body therapies, whereas both reiki and therapeutic touch therapies are energy field therapies. Tai chi is mind-body intervention. Acupressure and massage are body-based methods. Ayurvedic is a type of whole medical system.

The nurse is caring for a group of medical-surgical patients. Which patient is most at risk for developing an infection? a. A patient who is in observation for chest pain b. A patient who has been admitted with dehydration c. A patient who is recovering from a right total hip surgery d. A patient who has been admitted for stabilization of heart problems

ANS: C The patient who is recovering from a right total hip surgery has a large incision from the surgery. This break in the skin increases the likelihood of infection. Any break in the integrity of the skin and mucous membranes allows pathogens to enter and exit the body. The patient has had anesthesia, which depresses the respiratory system and has the potential to decrease the expansion of alveoli and to increase the chance of infection in the respiratory system. A patient who is having chest pain, experiencing dehydration, or being admitted with heart problems does not have open incisions that break the skin; therefore, his or her infection risk is lower.

A nurse is inserting a urinary catheter. Which technique will the nurse use to prevent a procedure-related accident? a. Pathogenic asepsis b. Medical asepsis c. Surgical asepsis d. Clean asepsis

ANS: C The potential for infection is reduced when surgical asepsis is used for sterile dressing changes or any invasive procedure such as insertion of a urinary catheter. Pathogenic and clean asepsis are not types of asepsis. Medical asepsis is not sterile.

A therapeutic touch practitioner scans the patient's body. What is the purpose of the practitioner's actions? a. To identify blocked moxibustion b. To identify universal life energy c. To identify energy obstructions d. To identify structural and functional imbalance

ANS: C The practitioner scans the body of the patient with the palms (roughly 2 to 6 inches [5 to 15 cm] from the body) from head to toe. While assessing the energetic biofield of the patient, the practitioner focuses on the quality of the qi and areas of energy obstructions, redirecting the energy to harmonize and move. Chiropractic therapy involves balancing structural and functional imbalance through spinal manipulation. Moxibustion is a traditional Chinese medicine technique that involves burning moxa, a cone or stick of dried herbs that have healing properties, on or near the skin. Reiki therapy transfers "universal life energy."

The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change? a. Donning clean goggles, gown, and gloves to dress the wound b. Donning sterile gown and gloves to remove the wound dressing c. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing d. Utilizing clean gloves to remove the dressing and clean supplies for the new dressing

ANS: C Utilize clean gloves (medical asepsis) to remove contaminated dressings and sterile supplies, including gloves and dressings (surgical asepsis-sterile technique) to reapply sterile dressings. Wearing sterile gowns and gloves is not necessary when removing soiled dressings. Donning clean gloves to dress a sterile wound would contaminate the sterile supplies. Utilizing clean supplies for a sterile dressing would not help in decreasing the number of microbes at the incision site.

An older-adult patient is newly admitted to a skilled nursing facility with the diagnoses of Alzheimer's dementia, lipidemia, and hypertension, and a history of pulmonary embolism. Medications brought on admission included lisinopril (Zestril, Prinivil), hydrochlorothiazide (Microzide), warfarin (Coumadin), low-dose aspirin, ginkgo biloba, and echinacea. Which potential interaction will cause the nurse to notify the patient's health care provider? a. Echinacea and warfarin b. Lisinopril and echinacea c. Warfarin and ginkgo biloba d. Lisinopril and hydrochlorothiazide

ANS: C Warfarin and blood thinners interact with ginkgo biloba (designed to improve memory). All herbal supplements should be evaluated with current pharmacological medications. The other options do not have interactions with each other.

The nurse is caring for a patient with leukemia and is preparing to provide fluids through a vascular access (IV) device. Which nursing intervention is a priority in this procedure? a. Review the procedure with the patient. b. Position the patient comfortably. c. Maintain surgical aseptic technique. d. Gather available supplies.

ANS: C You maintain surgical aseptic technique at the patient's bedside (e.g., when inserting IV or urinary catheters, suctioning the tracheobronchial airway, and sterile dressing changes) because patients with disease processes of the immune system are at particular risk for infection. These diseases include leukemia, AIDS, lymphoma, and aplastic anemia. These disease processes weaken the defenses against an infectious organism. Reviewing the procedure with the patient, positioning the patient, and gathering the supplies are all important steps in the procedure but are not the priority in the procedure since the patient already has a compromised immune response.

The nurse is performing the "Timed Get Up and Go (TUG)" assessment. Which actions will the nurse take? (Select all that apply.) a. Ranks a patient as high risk for falls after patients takes 18 seconds to complete b. Teaches patient to rise from straight back chair using arms for support c. Instructs the patient to walk 10 feet as quickly and safely as possible d. Observes for unsteadiness in patient's gait e. Begins counting after the instructions f. Allows the patient a practice trial

ANS: C, D, F The nurse instructs the patient to walk 10 feet (3 m) as quickly and safely as possible and observes for unsteadiness in the patient's gait. For accuracy, a patient should have one practice trial that is not included in the score. Patient taking less than 20 seconds to complete TUG is adequate for independent mobility. Score over 30 seconds is dependent and at risk for fall. Counting does not begin after instructions. The patient rises from a straight back chair without using arms for support.

A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take? a. Check on the patient once a shift. b. Encourage visitors in the early evening. c. Place all four side rails in the "up" position. d. Keep the patient on fall risk until discharge.

ANS: D A fall-reduction program includes a fall risk assessment of every patient, conducted on admission and routinely (see hospital policy) until a patient's discharge. The timing of visitors would not affect falls. All four side rails are considered a restraint and can contribute to falling. Individuals on high risk for fall alerts should be checked frequently, at least every hour.

The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease? a. Place the patient in a room with negative airflow. b. Wear a gown, gloves, face mask, and goggles for interactions with the patient. c. Transport the patient safely and quickly when going to the radiology department. d. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only

ANS: D Contact precautions are a type of isolation precaution used for patients with illness that can be transmitted through direct or indirect contact. Patients who are on contact precautions should have dedicated equipment wherever possible. This would mean, for example, that one blood pressure cuff and one stethoscope would stay in the room with the patient and would be used for that patient only. A gown and gloves may be required for interactions with a patient who is on contact precautions. A face mask and goggles are not part of contact precautions. A room with negative airflow is needed for patients placed on airborne precautions; it is not necessary for a patient on contact precautions. When a patient on contact precautions needs to be transported, the patient should wear clean gown, and hands cleaned, and the infectious material is contained or covered.

The nurse manager is evaluating current infection control data for the intensive care unit. The nurse compares past patient data with current data to look for trends. The nurse manager examines the infection chain for possible solutions. In which order will the nurse arrange the items for the infection chain beginning with the first step? 1. A mode of transmission 2. An infectious agent or pathogen 3. A susceptible host 4. A reservoir or source for pathogen growth 5. A portal of entry to a host 6. A portal of exit from the reservoir a. 3, 2, 4, 1, 5, 6 b. 1, 3, 5, 4, 6, 2 c. 4, 2, 1, 6, 3, 5 d. 2, 4, 6, 1, 5, 3

ANS: D For spread of infection, the chain has to be uninterrupted with an infectious agent, a reservoir and portal of exit, a mode of transmission, a portal of entry, and a susceptible host. The nurse manager is evaluating the chain of infection to determine actions that could be implemented to influence the spread of infection in the intensive care unit. Understanding the spread of infection and directing actions toward those steps have the potential to decrease infection in the setting.

A diabetic patient presents to the clinic for a dressing change. The wound is located on the right foot and has purulent yellow drainage. Which action will the nurse take to prevent the spread of infection? a. Position the patient comfortably on the stretcher. b. Explain the procedure for dressing change to the patient. c. Review the medication list that the patient brought from home. d. Don gloves and other appropriate personal protective equipment.

ANS: D Localized infections are most common in the skin or with mucous membrane breakdown. Wear gloves and other personal protective equipment as appropriate when examining or providing treatment to localized infected areas to create a protective barrier. Positioning the patient, explaining the procedure, and reviewing the medication list are all tasks that need to be completed, but they do not prevent the spread of infection.

A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls? a. 55 years old b. 20/20 vision c. Urinary continence d. Orthostatic hypotension

ANS: D Numerous factors increase the risk of falls, including a history of falling, being age 65 or over, reduced vision, orthostatic hypotension, lower extremity weakness, gait and balance problems, urinary incontinence, improper use of walking aids, and the effects of various medications (e.g., anticonvulsants, hypnotics, sedatives, certain analgesics).

During a relaxation therapy skills group, the instructor discusses the cognitive skill of learning to tolerate uncertain and unfamiliar experiences. Which skill is the nurse describing? a. Passivity b. Focusing c. Mindfulness d. Receptivity

ANS: D Receptivity is defined as the ability to tolerate and accept experiences that are uncertain, unfamiliar, or paradoxical. Passivity is the ability to stop unnecessary goal-directed and analytical activity. Focusing is the ability to identify, differentiate, maintain attention on, and return attention to simple stimuli for an extended period. Mindfulness is not a cognitive skill needed in relaxation therapy but is needed for meditation.

Which interventions utilized by the nurse will indicate the ability to recognize a localized inflammatory response? a. Vigorous range-of-motion exercises b. Turn, cough, and deep breathe c. Orient to date, time, and place d. Rest, ice, and elevation

ANS: D Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. One sign of the inflammatory response, particularly after an injury, is swelling or edema. Resting the affected injured area, using ice as ordered, wrapping the area to provide support—particularly if it is an extremity—and elevating the injured area will help to decrease swelling or edema. Turning, coughing, and deep breathing are utilized for postoperative patients and for immobilized patients to help prevent an infectious process such as pneumonia. Orientation to date, time, and place is an intervention utilized with many different types of patients who may be confused. Vigorous range of motion would irritate the inflammatory process. Range of motion is utilized for individuals who need to improve movement of their extremities, including immobilized patients.

The nurse is monitoring for the four categories of risk that have been identified in the health care environment. Which examples will alert the nurse that these safety risks are occurring? a. Tile floors, cold food, scratchy linen, and noisy alarms b. Dirty floors, hallways blocked, medication room locked, and alarms set c. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach d. Wet floors unmarked, patient pinching fingers in door, failure to use lift for patient, and alarms not functioning properly

ANS: D Specific risks to a patient's safety within the health care environment include falls, patient-inherent accidents, procedure-related accidents, and equipment-related accidents. Wet floors contribute to falls, pinching finger in door is patient inherent, failure to use the lift is procedure related, and an alarm not functioning properly is equipment related. Tile floors and carpeted or dirty floors do not necessarily contribute to falls. Cold food, ice machine empty, and hallways blocked are not patient-inherent issues in the hospital setting but are more of patient satisfaction, infection control, or fire safety issues. Scratchy linen, unlocked supply cabinet, and medication room locked are not procedure-related accidents. These are patient satisfaction issues and control of supply issues and are examples of actually following a procedure correctly. Noisy alarms, call light within reach, and alarms set are not equipment-related accidents but are examples of following a procedure correctly

The nurse is caring for a patient who is at risk for infection. Which action by the nurse indicates correct understanding about standard precautions? a. Teaches the patient about good nutrition b. Dons gloves when wearing artificial nails c. Disposes an uncapped needle in the designated container d. Wears eyewear when emptying the urinary drainage bag

ANS: D Standard precautions include the wearing of eyewear whenever there is a possibility of a splash or splatter, like when emptying the urinary drainage bag. Teaching the patient about good nutrition is positive but does not apply to standard precautions. Standard precautions apply to contact with blood, body fluid (except sweat), nonintact skin, and mucous membranes from all patients. Artificial nails are not worn when using standard precautions. Any needles should be disposed of uncapped, or a mechanical safety device is activated for recapping.

The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene? a. "The number for poison control is 800-222-1222." b. "Never induce vomiting if my grandchild drinks bleach." c. "I should call 911 if my grandchild loses consciousness." d. "If my grandchild eats a plant, I should provide syrup of ipecac."

ANS: D The administration of ipecac syrup or induction of vomiting is no longer recommended for routine home treatment of poisoning. The nurse must intervene to provide additional teaching. All the rest are correct and do not require follow up. The poison control number is 800-222-1222. After a caustic substance such as bleach has been drunk, do not induce vomiting. This can cause further burning and injury as the substance is eliminated. Loss of consciousness associated with poisoning requires calling 911.

A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel? a. Determining the need for restraints b. Assessing the patient's orientation c. Obtaining an order for a restraint d. Applying the restraint

ANS: D The application and routine checking of a restraint can be delegated to nursing assistive personnel. The skill of assessing a patient's behavior, orientation to the environment, need for restraints, and appropriate use cannot be delegated. A nurse must obtain an order from a health care provider.

The nurse is caring for a school-aged child who has injured the right leg after a bicycle accident. Which signs and symptoms will the nurse assess for to determine if the child is experiencing a localized inflammatory response? a. Malaise, anorexia, enlarged lymph nodes, and increased white blood cells b. Chest pain, shortness of breath, and nausea and vomiting c. Dizziness and disorientation to time, date, and place d. Edema, redness, tenderness, and loss of function

ANS: D The body's cellular response to an injury is seen as inflammation. Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. Systemic signs of inflammation include fever, malaise, and anorexia, as well as enlarged lymph nodes and increased white blood cells. Chest pain, shortness of breath, and nausea and vomiting are signs and symptoms of a cardiac alteration. Dizziness and disorientation to time, date, and place may indicate a neurologic alteration.

The nurse is caring for a patient who needs a protective environment. The nurse has provided the care needed and is now leaving the room. In which order will the nurse remove the personal protective equipment, beginning with the first step? 1. Remove eyewear/face shield and goggles. 2. Perform hand hygiene, leave room, and close door. 3. Remove gloves. 4. Untie gown, allow gown to fall from shoulders, and do not touch outside of gown; dispose of properly. 5. Remove mask by strings; do not touch outside of mask. 6. Dispose of all contaminated supplies and equipment in designated receptacles. a. 3, 1, 4, 5, 6, 2 b. 1, 4, 5, 3, 6, 2 c. 1, 4, 5, 3, 2, 6 d. 3, 1, 4, 5, 2, 6

ANS: D The correct order for removing personal protective equipment for a patient in a protective environment and for performing associated tasks is to remove gloves, remove eyewear, remove gown, remove mask, perform hand hygiene, leave room and close doors, and dispose of all contaminated supplies and equipment in a manner that prevents the spread of microorganisms.

The nurse is performing hand hygiene before assisting a health care provider with insertion of a chest tube. While washing hands, the nurse touches the sink. Which action will the nurse take next? a. Inform the health care provider and recruit another nurse to assist. b. Rinse and dry hands, and begin assisting the health care provider. c. Extend the handwashing procedure to 5 minutes. d. Repeat handwashing using antiseptic soap.

ANS: D The inside of the sink and the edges of the sink, faucet, and handles are considered contaminated areas. If the hands touch any of these areas during handwashing, repeat the handwashing procedure utilizing antiseptic soap. There is no need to inform the health care provider or be relieved of this assignment. If the hands are contaminated when touching the sink, drying hands and proceeding with the procedure could possibly contaminate and contribute to increased microbial counts during the procedure, resulting in infection for the patient. Extending the time for washing the hands (although this is what will happen when the procedure is repeated) is not the focus. The focus is to repeat the whole hand hygiene procedure utilizing antiseptic soap.

The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan? a. Impaired home maintenance b. Deficient knowledge c. Risk for poisoning d. Risk for injury

ANS: D The patient's behaviors support the nursing diagnosis of Risk for injury. The patient is confused, is pulling at the intravenous line, and is trying to climb out of bed. Injury could result if the patient falls out of bed or begins to bleed from a pulled line. Nothing in the scenario indicates that this patient lacks knowledge or is at risk for poisoning. Nothing in the scenario refers to the patient's home maintenance.

The nurse is providing an educational session for a group of preschool workers. The nurse reminds the group about the most important thing to do to prevent the spread of infection. Which information did the nurse share with the preschool workers? a. Encourage preschool children to eat a nutritious diet. b. Suggest that parents provide a multivitamin to the children. c. Clean the toys every afternoon before putting them away. d. Wash their hands between each interaction with children

ANS: D The single most important thing that individuals can do to prevent the spread of infection is to wash their hands before and after eating, going to the bathroom, changing a diaper, and wiping a nose and between touching each individual child. It is important for preschool children to have a nutritious diet; a healthy individual can fight infection more effectively. A health care provider, along with the parent, makes decisions about dietary supplements. Cleaning the toys can decrease the number of pathogens but is not the most important thing to do in this scenario.

A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up? a. "Every December is the time to change batteries on the carbon monoxide detector." b. "I will schedule an appointment with a chimney inspector next week." c. "If I feel dizzy when using the heater, I need to have it inspected." d. "When it is cold outside in the winter, I will use a nonvented furnace."

ANS: D Using a nonvented heater introduces carbon monoxide into the environment and decreases the available oxygen for human consumption and the nurse should follow up to correct this behavior. Checking the chimney and heater,changing the batteries on the detector, and following up on symptoms such as dizziness, nausea, and fatigue are all statements that are safe and appropriate and need no follow-up.

The nurse is completing an admission history on a new home health patient. The patient has been experiencing seizures as the result of a recent brain injury. Which interventions should the nurse utilize for this patient and family? (Select all that apply.) a. Demonstrate how to restrain the patient in the event of a seizure. b. Instruct the family to move the patient to a bed during a seizure. c. Teach the family how to insert a tongue depressor during the seizure. d. Discuss with the family steps to take if the seizure does not discontinue. e. Instruct the family to reorient and reassure the patient after consciousness is regained.

ANS: D, E Prolonged or repeated seizures indicate status epilepticus, a medical emergency that requires intensive monitoring and treatment. Family should know what to do. Family should reorient and reassure the patient after consciousness is regained. Never force apart a patient's clenched teeth. Do not place any objects into patient's mouth such as fingers, medicine, tongue depressor, or airway when teeth are clenched. Do not lift patient from floor to bed while seizure is in progress. Do not restrain patient; hold limbs loosely if they are flailing. Loosen clothing.