Fundamentals - Archer Review (1/3) - Safety/Infection Control

Choice A is correct. Mannitol is the preferred diuretic used for reducing the increased intracranial pressure. Mannitol is an osmotic diuretic that does not cross the blood-brain barrier. As a result; osmotic pressure increases in the plasma but not in the brain. A gradient is developed between plasma and brain cells, therefore causing a shift of fluids from the extracellular space into the blood vessels.

A 16-year old male arrives at the trauma bay after suffering from a head injury. He is postictal and is being intubated to protect his airway. After obtaining IV access, the doctor orders a diuretic. Based on the history provided, what diuretic will the doctor order? A. Mannitol B. Hydrochlorothiazide C. Spironolactone D. Furosemide

Choice A is correct. After performing any necessary life-saving means required, removing the client's clothing and decontaminating the client is the priority. Clothes are removed carefully to minimize the spread of contamination and subsequently placed in labeled containers. Clothing removal eliminates about 90% of external contamination. Therefore, removing the client's clothing and decontaminating the client should be the nurse's priority and initial action.

A client is rushed to the emergency department after exposure to radioactive materials in a workplace accident. The client's supervisor phoned ahead and informed the charge nurse of the chemical with which the client came in contact. What should be the initial action of the nurse? A. Remove all the client's clothing and decontaminate the client. B. Ask the client what happened during the accident. C. Decontaminate the room where the client was staying. D. Save the clothing for analysis.

Choice B is correct. Asking the client to elaborate on their concern is the most logical and therapeutic action. The client is likely misinformed about the disease transmission of HIV, and the nurse should encourage the client to verbalize their concerns. It also is appropriate for the nurse to respond to any misconceptions the client may have with compassion and facts.

A client requests to change rooms after overhearing that their roommate is positive for the human immunodeficiency virus (HIV). The nurse should take which appropriate action? A. Relocate the client to a private room B. Ask the client to elaborate on their concern C. Notify the risk manager of the request D. Place an additional divider in-between the two beds

Choice B is correct. Ensuring the bed alarm is on will help notify staff if the client is trying to get up unassisted and allow the staff to intervene and reduce their risk of falling. This client has a history of falls, and it is appropriate to provide this measure.

A client with a history of falls is admitted to the medical-surgical unit. The nurse should plan to implement which intervention to reduce this client's risk of falling? A. Encouraging the client to ambulate independently to improve muscle strength. B. Verify that the bed alarm is enabled during client rounding. C. Implementing a fall risk assessment every two days D. Implementing a restrictive mobility policy to minimize the potential of falls.

Choice D is correct. If you suspect that a piece of electrical care equipment may be faulty and you have a health care provider's (HCP) order for the immediate use of this equipment for the client, you should immediately remove it from service. You must not use this piece of equipment under any circumstances.

A health care provider (HCP) orders the immediate use of a piece of electrical care equipment for a client. When you go to use the piece of equipment, you immediately suspect it may be faulty. Your initial action should be which of the following? A. Try the piece of electrical care equipment and see if it becomes hazardous. B. Call the health care provider and report your suspicion. C. Ask the client if they want you to try the piece of electrical care equipment. D. Immediately remove the piece of electrical care equipment from service.

Choice A is correct. A complication of pneumonia is acute respiratory distress syndrome (ARDS). The hallmark of ARDS is hypoxemia which may manifest as altered mental status. The nurse should obtain vital signs with an emphasis on assessing the client's respiratory rate and pulse oximetry.

A nurse is caring for a client with pneumonia who is in bilateral wrist restraints. The client has developed confusion. The nurse should take which priority action? A. Obtain vital signs B. Release restraints and provide range of motion C. Auscultate lung sounds D. Assess skin integrity under each restraint

Choice B is correct. Following the oral consumption of gasoline or another hydrocarbon (i.e., lighter fluid, kerosene, etc.), inducing emesis is generally contraindicated. If vomiting is induced, the immediate hazard is aspiration, as even the aspiration of a small amount of a hydrocarbon can cause bronchitis and/or chemical pneumonia. More specifically, gasoline, kerosene, lighter fluid, mineral seal oil, and turpentine hydrocarbons are known to cause severe pneumonia if aspirated, thus making the induction of vomiting contraindicated. The inaccuracy contained within this statement by the parents indicates a need for additional teaching by the school nurse.

A school nurse is discussing poison prevention and management with a group of parents. Which statement by parents would indicate a need for additional teaching? A. "Containers of poisonous liquids need to be properly labeled." B. "In the event gasoline is ingested by my child, vomiting should be induced." C. "I may be able to give my child milk or water to dilute a corrosive poison while I rush them to the hospital." D. "All poisonous materials should be securely stored away from children."

Choice A is correct. One of the complications associated with the improper use of crutches is axillary nerve damage Supporting one's weight on the upper support of crutches is not recommended because it can lead to axillary nerve damage. Despite this warning, improper axillary weight bearing frequently occurs due to various factors (i.e., a lack of arm strength, fatigue, improper client instruction, inappropriate crutch fit, etc.).

One of the complications associated with the improper use of crutches is: A. Axillary nerve damage B. Solar plexus nerve damage C. Carpal tunnel syndrome D. Trigeminal nerve damage

Choice C is correct. Venous stasis, a complication of immobilization and bed rest, can be prevented using a sequential compression device (SCD), anti-embolic stockings, client positioning, range of motion exercises, and active leg exercises. When used in immobile or bedridden clients, these interventions will promote venous return and prevent venous stasis, deep vein thrombosis, and pulmonary emboli.

Select the hazard of immobility and complete bed rest that is accurately paired with an appropriate preventive measure. A. Respiratory secretion accumulation: Oxygen supplementation therapy B. Dorsiflexion of the foot: Using a foot board or boots to maintain proper positioning C. Venous stasis: The use of a sequential compression device D. Skin breakdown: The use of a tilt table for clients at risk

Choice D is correct. Out of this client assignment, the nurse should assign the client who has C. diff and experiencing fecal incontinence to the private room. The other clients do not require immediate isolation, as this client should have contact precautions initiated. Specifically, the client should have contact precautions with bleach, as bleach is the only effective cleaning agent. The nurse should reinforce effective transmission-based precautions.

The charge nurse is making room assignments for assigned clients. The charge nurse has one private room remaining, the nurse should assign the private room to the client admitted with A. epilepsy, who had a tonic-clonic seizure two hours ago. B. an indwelling urinary catheter and has proteus mirabilis in the urine. C. viral meningitis and has a fever. D. clostridium difficile who is incontinent of stool.

Choices A, C, E, and F are correct. If the charge nurse observes these actions, they require follow-up because they are incorrect. Soiled linens should not be placed on the floor because they contaminate other surfaces in the facility. Once soiled linens are removed, they should go in the appropriate fluid-resistant containers. Disposable dishware and utensils are not required for clients on transmission-based precautions. The hot water and detergents used in dishwashers are sufficient to decontaminate dishes and eating utensils, so the client should be provided reusable, washable dishware. If a surgical hand scrub is being performed, the appropriate technique is to avoid contamination by holding hands above the elbows as fluid flows in the direction of gravity. Gloves are removed first during the doffing of PPE. The sequence for doffing (removing PPE) is gloves, face shield or goggles, gown, and mask or respirator.

The charge nurse is observing infection control practices in the nursing unit. Which observation by the charge nurse requires follow-up? Select all that apply. - Soiled linens are placed on the floor during a bed bath and linen change. - A disposable blood pressure cuff is used for a client on contact precautions. - Disposable dishes are placed in the room for a client on droplet precautions. - Reusable eye protection is cleaned and disinfected after each client encounter. - A surgical hand scrub is performed with the hands lower than the elbows. - Gloves are doffed last while removing personal protective equipment (PPE).

Choice D is correct This observation requires follow-up because a belt restraint should be applied to the client's waist - not the chest. Having a belt restraint secured over the client's chest is inappropriate.

The charge nurse is performing safety rounds on clients in the nursing unit. Which observation requires follow-up? A client with A. an indwelling urinary catheter hanging from the bed frame. B. right-sided weakness with their cane on the left side of the bed. C. a history of falling given a bedside commode. D. a belt restraint was applied and secured over the chest.

Choice C is correct. Disseminated herpes zoster requires airborne and contact precautions until lesions are dry and crusted. This client requires a private room because negative airflow is necessary, and thus, the door must be kept closed. The client should not be placed in a room with another client because of the high risk of disease transmission.

The charge nurse is reviewing room assignments and recognizes that only one private room is left. It would be appropriate to assign this room to the client with A. human immunodeficiency virus (HIV). B. delirium tremens who is agitated. C. disseminated herpes zoster. D. an implantable port that is accessed.

Choices A, B, and C are correct. During an external disaster such as a mass shooting, it is reasonable for the nurse to anticipate a surge in clients. To accommodate the surge of individuals, the nurse should advocate for the timely disposition of clients (either admission or discharge) to clear up necessary space. If a client is discharged but cannot leave until the transportation is arranged, they should be placed in a designated discharge area. The charge nurse will need to modify the nurse/client ratio as the influx in clients will require more staffing resources.

The emergency department charge nurse was notified of a mass shooting at a nearby shopping mall. The charge nurse should take which action to prepare for the surge in clients? Select all that apply. - Work to arrange timely discharge and admission for appropriate clients. - Establish a holding area for discharged clients not able to go home. - Modify the nurse/client ratio to accommodate the surge levels. - Instruct staff to switch from electronic to paper documentation. - Prepare to provide frequent updates to local media.

Choice D is correct. Norovirus is a virus that is commonly implicated in gastroenteritis. The transmission of norovirus primarily occurs through surfaces contaminated with norovirus and then touching the mouth or other food items. Further, norovirus may be transmitted by having direct contact with another person who is infected or eating food or drinking liquids that are contaminated with norovirus. The most effective disinfectant for norovirus is bleach. It is also recommended that hand hygiene be performed with soap and water as it is superior to alcohol-based hand rubs.

The infection control nurse is responding to an outbreak of norovirus in the facility. The nurse should recommend that A. staff wears a surgical mask when providing client care. B. disposable utensils and dishware are used for meals. C. dietary staff wears a face shield when preparing client meals. D. commonly touched surfaces be disinfected with a bleach solution.

Choice C is correct. Neisseria meningitidis is spread by infected droplets, and the nurse should wear a surgical mask while working within three feet of the client. Three feet is the distance for droplets to spread to another individual. If the client with Neisseria meningitidis should leave the room, they should wear a surgical mask.

The infection control nurse reviews guidelines with other nurses. Which of the following statements by the nurses would indicate a correct understanding of the teaching? A. "The nurse should wear a surgical mask when transporting a client with active pulmonary tuberculosis (TB)." B. "Disposable utensils must be provided for a client infected with hepatitis B." C. "A surgical mask should be worn when working within three feet of the client infected with Neisseria meningitidis." D. "A surgical gown should be applied when entering a client's room with bacterial pneumonia."

Choice B is correct. The nurse should assess the client's skin while restrained because friction and shearing injuries may develop. Choice C is correct. Behavioral status should be assessed at every assessment because if the client's behavior improves, the nurse should discontinue the restraint. Failure to do so may result in litigation specific to false imprisonment. Choice D is correct. The client's vital signs are always assessed to determine the client's physical stability. If the client's vital signs become unstable, the nurse should immediately discontinue the restraint.

The nurse assesses a client who requires bilateral wrist restraints for agitation and hostility toward staff. When performing follow-up assessments, what data is necessary for the nurse to obtain? Select all that apply. previous restraint use skin integrity behavioral status vital signs urinary continence

Choice A is correct. For a client found down on the ground, the nurse should immediately implement basic life support measures, including initially assessing the client's level of consciousness. If the client is unconscious, the nurse should stay with the client and shout for help.

The nurse enters a client's room who is found on the ground. The nurse should perform which initial action? A. Assess the client's level of consciousness B. Examine the client for injuries C. Call the rapid response team (RRT) D. Palpate the client's carotid pulse

Gown Mask Goggles Gloves

The nurse evaluates a student's ability to appropriately apply personal protective equipment (PPE). It would indicate effective teaching if the student dons PPE in which order? Place the steps in the appropriate order. Press and hold an option to rearrange Mask Gown Goggles Gloves

Choice B is correct. The nurse's initial action should be to wash the area with soap and water thoroughly. The nurse should not squeeze the wound. Following this, the nurse should report the incident to the supervisor and complete the exposure report sheet.

The nurse has just given an intradermal injection of PPD to a client in the clinic when she accidentally sticks herself in the finger with the used needle. What is the initial action of the nurse? A. Fill out an incidence occurrence report. B. Wash the area with soap and water right away. C. Ask the client if he has HIV or hepatitis. D. Put an antibiotic cream and bandage over the site.

Choice A is correct. Standard precautions are used for a client with erythema infectiosum. Droplet precautions would only be necessary if the client is immunocompromised.

The nurse in the emergency department (ED) is caring for a child with erythema infectiosum (Fifth disease). Which transmission-based precautions should the nurse implement? A. Standard B. Droplet C. Contact D. Airborne

Choice C is correct. Standard precautions are utilized in the management of inhalation anthrax. Inhalation anthrax is not transmitted from person to person, and its vector is contaminated materials, such as wool, hides, or hair.

The nurse in the emergency department is preparing to receive a client exposed to inhalation anthrax. The nurse plans to implement A. droplet precautions. B. airborne precautions. C. standard precautions. D. contact precautions.

Choice A is correct. Although hepatitis B needs to be reported to the public health department, a client with hepatitis B does not need to be isolated. An appropriate client to room with would be an individual receiving intravenous diuretics for heart failure as this client does not have any transmissible pathogens.

The nurse is admitting a client diagnosed with hepatitis B. The nurse would be able to cohort the client in the same room with which of the following clients? A client with A. heart failure receiving diuretics B. bacterial meningitis receiving antibiotics C. prostate cancer receiving brachytherapy D. varicella prescribed antivirals

Choice A is correct. For the client being physically violent towards staff, the nurse may, as prescribed, chemically restrain the client or physically restrain the client. The appropriate option for this client is to seclude the individual or use soft wrist restraints. Another alternative to soft wrist restraints for a client who is violent is the use of leather restraints attached to all four extremities.

The nurse is caring for a client who has been physically violent towards staff. The nurse prepares to restrain the client using A. soft wrist restraints. B. mitten restraints. C. elbow restraints. D. waist belt restraint.

Choice D is correct. Generalized urticaria typically manifests when the client is experiencing an allergic reaction. This skin condition does not require isolation. The nurse should plan to care for this client using standard precautions.

The nurse is caring for a client who has generalized urticaria. The nurse should implement which disease transmission precautions? A. Airborne precautions B. Droplet precautions C. Contact precautions D. Standard precautions

Choice B is correct. Rubella is known as German measles and requires droplet precautions. The nurse is right to wear a surgical mask when engaging with the client. The transmission mode for rubella is a droplet mode of communication where the spread occurs with particle drops larger than 5 microns.

The nurse is caring for a client who has rubella. The nurse should isolate the client using which of the following? A. Airborne precautions B. Droplet precautions C. Contact precautions D. Standard precautions

Choice D is correct If restraints are necessary for this client, the most appropriate restraint would be a waist belt restraint. This restrains the client's ability to stand up, which is the device's intent.

The nurse is caring for a client who repeatedly attempts to get up from their wheelchair unassisted and has fallen twice. The primary healthcare provider (PHCP) prescribes restraints. Which type of restraint does the nurse anticipate? A. Soft wrist restraints B. Mitten restraints C. Seclusion D. Waist belt restraint

Choice A is correct. The most important action a nurse can take to prevent a healthcare acquired infection is to frequently wash their hands. Hand hygiene is a proven and effective measure to decrease the transmission of pathogens. The nurse should wash their hands when they are visibly soiled, before and after contact with the client. Alternatively, the nurse may use alcohol-based sanitizers.

The nurse is caring for a group of premature infants. Which action is most important in preventing healthcare-acquired infection? A. Performing frequent hand hygiene B. Disinfecting commonly touched surfaces C. Screening visitors for illness D. Administer prophylactic antibiotics

Choice D is correct. When evacuating clients from a fire, the nurse should evacuate the client who is in immediate danger (the client closest to the fire). Once that has been completed, the nurse should evacuate the most ambulatory client. This is because ambulatory clients require fewer resources and can be speedily evacuated. The client with acute glomerulonephritis is most ambulatory and requires fewer resources. This client only has one device, and the nurse can quickly change the system to a leg bag or instruct the client to keep the bag below their bladder.

The nurse is caring for assigned clients. Which client should be evacuated first during a fire? A client with A. below-the-knee amputation receiving patient-controlled analgesia. B. acute respiratory distress syndrome receiving mechanical ventilation. C. advanced dementia receiving enteral feedings and intravenous fluids. D. acute glomerulonephritis with an indwelling urinary catheter.

Choice A is correct. Infected droplets spread pertussis. Therefore, the nurse must wear a surgical mask within three feet of the client. Visitors must also wear the surgical mask, and during client transport, the client should wear a surgical mask - not N95. Choice H is correct. The client should wear a surgical mask outside their assigned room to prevent the transmission of pertussis to others in the facility. If the client is at home, they should wear a surgical mask in public or around others.

The nurse is developing a plan of care for a client with pertussis. It would be appropriate for the nurse to include which interventions? Select all that apply. - Wear a surgical mask when working within three feet of the client - Provide disposable dishes for meals - Keep the client's room door closed - Provide the client with a portable fan - Maintain negative air pressure - Apply a N95 mask to the client during transport - Place the client in a room near the nurse's station - Apply a surgical mask to the client during transport

Choices A and E are correct. Alcohol-based hand rubs (ABHRs) are recommended over hand hygiene with soap and water because of the risk of errors associated when washing hands with soap and water. Specific criteriahave been established for when a healthcare worker should use an ABHR, and these two circumstances are appropriate.

The nurse is discussing infection control with a group of nursing students. Which indication would be appropriate for the nurse to use an alcohol-based sanitizer? Select all that apply. - Immediately before touching a client - After applying sterile gloves - When changing linens for a client infected with Clostridium difficile - After changing a diaper for an infant infected with norovirus - When cleaning a soiled body part then transitioning to a non-soiled body part - While wearing artificial nails

Choices C and E are correct. Infected droplets primarily spread influenza. Wearing a surgical mask when providing care is essential. Finally, cleaning common surfaces with a cleaning agent of at least 70% isopropyl alcohol is important as the influenza virus may survive on these surfaces.

The nurse is educating staff on infection control. Which of the following statements by the nurse would indicate a correct understanding of infection control guidelines for influenza? Select all that apply. - Limiting visitation to 30 minutes per day. - Keeping the door to the client's room closed. - Wearing a surgical mask when providing care. - Placing the client in a room at the end of the hall. - Cleaning common surfaces with 70% isopropyl alcohol.

Choice B is correct. A child should walk their bike through busy intersections to reduce their risk of being hit by an automobile.

The nurse is educating the parents of a child who plans on riding their bicycle. Which statements, if made by the parents, indicate effective understanding? A. "I should tell my child to ride their bike against the traffic pattern." B. "I should instruct my child to walk their bike through busy intersections." C. "Wearing a helmet is only necessary when my child is riding near a busy intersection." D. "My child can ride their bike barefoot as long as it's short distances."

Choice A is correct. When a sterile surface comes in contact with a liquid, the sterile object or field becomes contaminated. Even though the spilled water is sterile, it creates moisture and may disrupt the sterile protective barrier. The nurse should intervene because microorganisms travel to the sterile object if moisture leaks through the protective covering of a sterile package. This observation requires follow-up because the sterile field needs to be discarded and re-established.

The nurse is observing the surgical aseptic technique of a nursing student. Which observation by the nurse requires follow-up? A. Spills sterile water onto the sterile field B. Uses sterile gloves to handle sterile supplies on a sterile field C. Has sterile gauze placed into the sterile field D. Keeps the sterile field above their waist

Choices B, C, D, and E are correct. Reducing medical errors is a continuous process,, and several proven factors may mitigate errors. These factors include: Having nurse-to-nurse bedside handoff reporting. Not only does this process increase client satisfaction by having the client participate, but it allows for errors to be noted by two individuals instead of one. For example, if an infusion pump is malfunctioning or administering the wrong dose. Bedside handoff reporting also mitigates distractions from being in the hallway or at the desk where it may be loud. A standardized handoff reporting (ISBAR) is helpful because it keeps communication concise to pertinent information. This standardized tool is useful because it keeps the communication process structured,, minimizing the risk of omission. Fatigue is a common source of errors. One way to minimize fatigue is to ensure all staff is taking uninterrupted breaks. Poor lighting and distractions continually contribute to errors, and increasing lighting around critical pieces of equipment, such as mediation dispensaries, may be helpful to reduce errors regarding reading product labels and drawing up accurate medication dosages.

The nurse is part of a committee tasked with reducing medical errors in the nursing unit. Which of the following recommendations should the nurse make to the committee? Select all that apply. - Increase the number of verbal orders given from primary healthcare providers - Nurse-to-nurse bedside handoff reporting - Handoff reporting using the ISBAR framework - Ensure staff are taking uninterrupted breaks - Increase the lighting around the medication dispensing machines

Choice A is correct. Lyme disease is not transmitted human-to-human (a tick transmits it). This client should be placed on standard precautions as contact precautions are inappropriate. This client's room assignment requires follow-up.

The nurse is reviewing client room assignments. Which room assignment requires modification? See the image below. View Exhibit A. Room 1 B. Room 2 C. Room 3 D. Room 4

Choice B is correct. An INR of 3.5 seconds is elevated and needs to be reported because the client may bleed.

The nurse is reviewing the laboratory results of a patient scheduled for surgery. Which of the following should be reported to the primary health care provider (PHCP)? A. Glycosylated hemoglobin (HbA1c) of 7.2% B. International Normalized Ratio (INR) of 3.5 C. Hematocrit (Hct) of 42% D. Blood urea nitrogen (BUN) level of 5

Choice B is correct. The nurse should immediately wash the affected area with soap and water for a needlestick injury. Once this is completed, the nurse should notify the supervisor and implement the facility's needlestick injury protocol which may involve assessing the client for bloodborne pathogens. This protocol may also require post-exposure prophylaxis for blood-borne pathogens such as human immunodeficiency virus (HIV). Applying pressure to a finger or hand to make it 'bleed' is not recommended and only causes more trauma to the affected area.

The nurse is starting a peripheral vascular access device (VAD) and suffers a needlestick injury following the initiation of VAD. The nurse should take what action? A. Ask the client if they have the hepatitis A virus (HAV) B. Wash the affected extremity with soap and water C. Document the incident in the client's medical record D. Discontinue the vascular access device

Choice D is correct. This action requires follow-up, as the CT scan should not be canceled if the client has iodine or shellfish allergies. Previously, it was disseminated that allergy to shellfish/seafood (because they contain iodine) and allergy to topical iodinated products conferred cross-allergy with iodine-containing contrast dyes. Iodine is found ubiquitously in the form of thyroid hormones, and there is no such thing as an allergy to systemic iodine. There is no evidence to support this notion; therefore, current guidelines do not suggest treatment plan modification based on a history of shellfish or seafood allergy alone. According to the American College of Radiology (ACR) Manual on contrast media, there is no evidence to support the continuation of this old practice of inquiring if the client has an allergy to shellfish.

The nurse is supervising a newly hired nurse preparing a client for a computed tomography (CT) scan of the brain with intravenous (IV) contrast. Which action by the newly hired nurse requires follow-up? A. Encourage fluids when the client returns from the scan B. Confirm that the consent form is signed. C. Raise the side rails of the client's stretcher during transport D. Cancel the CT scan if the client reports a shellfish allergy

Choice A is correct. The specific pathogen that causes diphtheria is Corynebacterium diphtheriae. This bacteria can be prevented by vaccination. Choice B is correct. A primary prevention strategy for diphtheria is vaccination beginning at two months of age. Several variations of the vaccine are available. Choice C is correct. Diphtheria can manifest in cutaneous or pharyngeal forms. Large droplets can spread pharyngeal diphtheria, so one must use droplet precautions. Cutaneous diphtheria is transmitted via direct contact with the skin sores of an infected person, carriers, or contaminated articles.

The nurse is teaching a continuing education course on communicable diseases. Which of the following statements should the nurse make about diphtheria? Select all that apply. - "The organism that causes this condition is Corynebacterium diphtheriae." - "Vaccination is available starting at two months of age." - "Transmission of the cutaneous diphtheria is via direct contact with the infected person." - "Airborne precautions are required for individuals with pharyngeal diphtheria." - "Diphtheria is caused by a virus and is highly contagious."

Choices B, C, and E are correct. Incident (sometimes termed occurrence or event) reporting is required when any activity deviates from the norm. The nurse should report events that are inconsistent with the routine care of a client or are inconsistent with the usual operations of the health care facility. Events such as client complaints regarding their care, leaving against medical advice (AMA), and threatening a nurse with bodily harm are all examples of incidents requiring factual reporting. Additional criteria include inadvertent destruction of a client's property, a client fall, and a medication or treatment error.

The nurse is teaching a group of students on incident reports. Which of the following situations would require an incident report? Select all that apply. A client - requesting to view their medical record. - complaining about poor care from a nurse. - leaving against medical advice (AMA). - requesting an increase in pain medication. - threatening a nurse with bodily harm.

Choices C and D are correct. Impetigo is a contagious infection of the skin commonly seen in young children. This condition is highly infectious, and the nurse should utilize standard and contact precautions. Part of this involves using disposable client care equipment (blood pressure cuff, thermometer, etc.). Contact precautions require the nurse to wear a gown and gloves when engaging in client care.

The nurse is triaging a child with suspected impetigo. Which action should the nurse take? Select all that apply. Initiate droplet precautions Set up a decontamination room Use a disposable blood pressure cuff Initiate contact precautions Apply sterile gloves while examining the client

Choices A and E are correct. An older patient with impaired vision that lives alone has significant risk factors for falls. The nurse should follow up if the client states they secured the scattered rugs with tape. The client should not have any scattered rugs. Finally, a client climbing the stairs to use the bathroom increases the risk of falls. The nurse should advise the client to use the closest bathroom.

The nurse is visiting an older adult client with impaired vision. It would be necessary for the nurse to follow up if the client states which of the following? Select all that apply. - "I secured my throw rugs to the floor with tape." - "I switched to using an electric shaver instead of a razor." - "I usually sit in a recliner while I listen to the television." - "I use different shaped containers with lids to organize my medications." - "I use the upstairs bathroom instead of the one downstairs."

Choice A is correct. Client safety is a priority, and the nurse should rescue (or evacuate) the client who is closest to the fire.

The nurse observes a fire in a client's room. The nurse should take which initial action? A. Rescue the client B. Extinguish the fire C. Enable the fire alarm D. Place a linen blanket over the fire

Choice A is correct. The nurse appropriately removed the client from the room where the fire was located. After removing the client, the nurse must summon help by activating a fire alarm. Activating the fire alarm is the next action because the nurse should not delay getting assistance to the area, and by obtaining aid, the nurse is promoting safety by protecting the other clients. After completing this, the nurse should contain the fire by closing the client's door.

The nurse observes that a fire has ignited in the client's room. After removing the client from the room, the nurse should then A. activate the fire alarm. B. extinguish the fire. C. contact the nursing supervisor. D. close the door to the client's room.

The findings that require intervention by the nurse include the following - Scatter rugs at the bottom of the stairs: scatter rugs should not be used because they reduce the traction on the ground, and the edges of these rugs may cause a client to fall. Smoke detector present without a battery: the smoke detector should have a functioning battery. The battery should be tested every six months. Extension cord covered with a rug: a rug should not cover an extension or electrical cord because of the fire risk. Instead, electrical and extension cords should be against a wall behind furniture. Unlabeled household chemicals under the sink: household chemicals should be labeled to avoid accidental mixing (for example - bleach being mixed with ammonia) that may create a significant hazard. Medications mixed in various containers: medications should not be mixed in containers. This may cause a client to take the wrong medication inadvertently. Medications should be in their original labeled container, and the client may request labels that have a bigger font size.

The nurse performs a home safety survey for an older adult Click to specify the findings that require intervention by the nurse Living area Scatter rugs at the end of the stairs Smoke detector present without a battery Stairs present with sturdy hand rails New light fixtures installed and connected in a grounded electrical outlet Extension cord covered with an anti-skid area rug Kitchen Unlabeled household chemicals under the sink Fire extinguisher present 30 feet from the stove Bathroom Rubber mats in the bathtub Grab bars installed in the shower Medications mixed in various containers

Choice B is correct. During any mechanical lift transfer, the nurse should instruct the client to fold their arms over the chest, preventing injuries to the client's arms during the transfer.

The nurse plans to use a mechanical lift to transfer a client from a stretcher to a wheelchair. Which appropriate action should the nurse take? A. Keep the stretcher's side rails raised during the transfer B. Instruct the client to fold their arms over their chest C. Apply gloves and gown for this procedure D. Unlock the wheels on the stretcher and wheelchair

Choice D is correct. An 11 mm induration after 48 to 72 hours would be recorded as a positive result. However, this does not confirm pulmonary tuberculosis, as further testing (chest x-ray) is required to determine if the client has latent pulmonary tuberculosis. The PPD is not a confirmatory test for pulmonary tuberculosis - a sputum sample is used to confirm an active infection, and a chest x-ray is used for latent infection.

The occupational health nurse assesses a health care worker's purified protein derivative (PPD) test and measures 11 mm of induration. The nurse should interpret this finding as A. a confirmatory test result for pulmonary tuberculosis. B. a false-negative test result. C. the healthcare worker requires immediate isolation using airborne isolation precautions. D. further testing is required.

Choice B is correct. The most common location of back injuries, especially in the context of workplace-related injuries, is typically the lumbar spine.

The occupational health nurse is conducting an in-service on reducing back injuries. It would be correct for the nurse to identify that the most common location of the injury is the A. cervical spine. B. lumbar spine. C. thoracic spine. D. pelvis.

Choice D is correct. You should tell the new graduate nurse that the black-colored triage tags on the incoming victims mean that the victims are in a severe medical crisis, and they have little chance of survival. In mass casualty scenarios, an advanced triage system is implemented and involves a color-coding scheme using red, yellow, green, white, and black tags. Remember the "DIME" acronym: Delayed; Immediate, Minor, Expectant. Red tags- IMMEDIATE - highest priority treatment/transfer. These patients cannot survive without immediate treatment but have a high chance of post-treatment survival. E.g. Tension pneumothorax, cardiac tamponade, massive hemorrhage. Yellow tags- DELAYED - medium priority. No immediate danger of death, stable but will still need hospital care. Under normal circumstances, these patients will be treated immediately, but in mass casualty scenarios, they are medium priority. E.g. isolated humerus or femur fracture. Green Tags- MINOR - lowest priority - those with minor injuries, ambulating ("walking" wounded). E.g. abrasions sprain. These are attended to after high and medium-priority patients are addressed. Black Tags- EXPECTANT - keep comfortable, pain medications

There is a massive airline crash near your acute care facility. As the victims of this massive external disaster arrive at your facility, your new graduate nurse asks you what the black-colored triage tags on the incoming victims indicate. How should you respond to this new nurse? A. The victims are the lowest priority for care. B. The victims have life-threatening injuries and are in need of immediate care. C. The victims are always dead. D. The victims are in a severe medical crisis, and they have little chance of survival.

Choice A is correct. To prevent falls; the environment should be well lit. Night lights should be used if necessary. Other factors in assessing include removing loose scatter rugs, removing spills, and installing handrails and grab bars as appropriate. While home health nurses cannot expect to change a family's living space and lifestyle, they can express their concern and react appropriately when a situation suggests that an injury is imminent. Nurses must document information they provide and the family's response to the instruction and make ongoing assessments about the family's use of safety precautions. Walkways and stairways (inside and outside) should also be inspected. Note any uneven sidewalks or paths, broken or loose steps, absence of handrails, or placement on only one side of stairs, insecure bars, congested hallways, or other traffic areas, and adequacy of lighting at night. Some important things for the home health nurse to assess, educate the patient about, and document include: Floors: Note uneven and highly polished or slippery floors and any unanchored rugs or mats. Furniture: Note the hazardous placement of furniture with sharp corners. Note chairs or stools that are

What is the most important factor to consider when assessing a home health patient on the risk of falls? A. Correct illumination of the environment B. Amount of regular exercise C. The resting pulse rate D. Status of salt intake

Choice C is correct. The patient taking Ginkgo Biloba (herbal), aspirin, and vitamin E may have to postpone surgery due to the increased risk for excessive bleeding, as each of these substances has antiplatelet and/or anticoagulant properties. Ginkgo Biloba can further potentiate aspirin's antiplatelet effect and may increase the bleeding tendency. Surgeons usually require aspirin and other antiplatelet agents to be held at least seven days before significant surgeries.

When doing presurgical assessments of patients in an ambulatory care center, which patient would the nurse report to the surgeon as possibly needing surgery to be postponed? A. A 20-year-old patient who is a vegan. B. An elderly client who takes daily nutritional drinks. C. A 40-year-old patient who takes ginkgo biloba and an aspirin daily. D. An infant who is breastfeeding.

Choice C is correct. Carbon monoxide is a hazardous gas that can be identified in the home with a simple and relatively inexpensive monitor and alarm similar to a smoke alarm. This odorless and colorless gas can be deadly, so it is recommended that all homes have a carbon monoxide alarm.

Which hazardous gas can be identified in the home with a simple and relatively inexpensive monitor and alarm similar to a smoke alarm? A. Ozone B. Nitrous oxide C. Carbon monoxide D. Carbon dioxide

Choice A is correct. A young child may place small or loose parts of toys in his mouth. A toy that is safe for a 10-year-old child could be deadly for a toddler.

Which of the following children would the nurse identify as a priority for having the greatest risk for choking and suffocating? A. A toddler playing with his 9-year-old brother's construction set. B. A 5-year-old eating yogurt for a snack. C. An infant asleep in her crib without a blanket. D. A 3-year-old drinking a glass of juice.

Choice D is correct. An explanation of what may have led to the incident is NOT included in an incident or accident form or report. Comments about what may have led to the event are speculative and not factual. Only facts, such as the condition of the floor after a client fall, are documented on an incident or accident form or report.

Which of the following must NOT be included in an incident or accident form or report? A. The name of the person completing the report. B. The name of the client and if anyone was injured. C. The location of the incident or accident. D. An explanation of what may have led to the incident.

Choice A is correct. Each and every hospital employee on duty during a "Code Pink" would immediately respond and perform their specified role per hospital policy, regardless of the unit the individual was staffing. Here, the fact that you are staffing the adult medical-surgical area has no bearing on whether you have an obligation to respond. You must always respond to each Code as if it were an actual emergency.

You are a nurse working on an adult medical-surgical floor when you hear "Code Pink" repeated three times over the hospital-wide speaker system, indicating an infant or child abduction. Since you know the hospital has infant/child abduction drills every two months, and you are working in an area without infants or pediatric clients, you should do which of the following? A. You must respond and perform your role in this "Code Pink." B. Ask the unit secretary to respond to the "Code Pink" for you. C. Ignore the "Code Pink" because you are caring for clients. D. Ignore the "Code Pink," as you are not staffing in obstetrics, the nursery, NICU, or pediatrics.

Choice C is correct. The CDC and experts at the American Academy of Pediatrics agree that there is no credible evidence that the MMR vaccine causes autism spectrum disorder (ASD). Some of the concerns may be because children typically get the MMR vaccine at about the same time that signs of ASD appear. In fact, in 2013, the CDC conducted a study that showed that vaccines do not cause ASD. This study showed that the antigens in vaccines that produce antibodies were the same between children diagnosed with ASD and children without ASD. Currently, there are no MMR vaccines that contain mercury. Although there is no evidence that mercury causes ASD, mercury was removed from all childhood vaccinations by 2001. The exception to that is that some multi-dose flu vaccines may still contain traces of thimerosal (a chemical containing mercury).

You are educating a mother about the association between autism and the MMR vaccine. You know that the mother understands your instructions when she says: A. "My child should not get the vaccine since it is known to cause autism." B. "My child should get the individual immunizations for measles, mumps, and rubella since the individual vaccines do not cause autism." C. "My child should get the MMR immunization since there is no evidence that it causes autism." D. "My child should not get the immunization because it contains mercury."

Choice B is correct. Stagnant water and food particles can be a breeding ground for pathogenic microorganisms. A patient with an AIDS diagnosis is susceptible to contracting illness/infections more quickly due to the deficiency in his/her immune system. The focus of education should include measures to protect the patient from contracting illnesses from others.

You are the nurse performing education for a patient with AIDS at the community clinic. Which of the following statements is an example of appropriate teaching? A. "Do not wash your dishes with your roommate's dishes." B. "Clean all utensils and dishes before reusing them." C. "Do not use the same shower or toilet as your roommate." D. "Hand sanitizer is not necessary unless you plan on touching someone else."

Choices B, C, and D are correct. Meningococcal meningitis is transmitted through respiratory droplets from infected individuals. After exposure, symptoms will usually appear within 3 to 4 days. The CDC does not recommend universal prophylaxis during an outbreak, but prophylactic treatment should be provided for individuals in close contact with the infected individuals. A single dose of ciprofloxacin or four doses of rifampin over two days can be useful in preventing the acquisition of the disease. Meningococcal conjugate vaccine (MCV4) is the preferred vaccine for at-risk individuals in this group. College students often receive this vaccination before attending school.

You work in a community clinic in a large city. There has been a recent outbreak of meningococcal meningitis at the local university and students who have been in contact with the sick students have been advised by public health officials to obtain prophylactic treatment. Which of the following would be helpful in preventing this disease? Select all that apply. Amoxicillin Ciprofloxacin Rifampin Meningococcal conjugate vaccine Vancomycin

Choice D is correct. A central line is a significant risk factor for a client to develop a central line-associated bloodstream infection (CLABSI). This occurs because of suboptimal sterile technique during insertion and/or inappropriate dressing changes. Additionally, TPN is a risk factor as the high glucose content makes the client more likely to develop a bacterial or fungal infection. TPN increases the risk for a CLABSI compared to solutions such as 0.9% saline.

A nurse is conducting infection control assessments on the nursing unit. Which client is at the greatest risk for infection? A client A. withdrawing from alcohol and is malnourished. B. receiving methylprednisolone for an asthma exacerbation. C. has an external urinary catheter device for urinary incontinence. D. receiving total parenteral nutrition (TPN) via a central line.

Choice A is correct. The charge nurse should consult the infection control nurse for client placement alternatives, as the pediatric client with pulmonary tuberculosis requires airborne isolation.

A pediatric client with pulmonary tuberculosis (TB) is scheduled to be admitted to the pediatric unit when the charge nurse learns the remaining private room on the unit was filled on the prior shift. No other pediatric TB clients are currently admitted. What is the most appropriate action for the charge nurse? A. Contact the infection control nurse B. Room the client with an uninfected client 6 feet apart C. Place the client with the varicella client currently in the airborne isolation room 6 feet apart D. Refuse to admit the pediatric TB client

Choice B is correct. Grapefruit juice and calcium channel blockers may combine to cause toxic effects, specifically by reducing the body's ability to metabolize calcium channel blockers, especially nifedipine. This finding should immediately concern the nurse, necessitating further teaching regarding calcium channel blockers (i.e., the client's amlodipine).

The community health nurse is performing a home visit for a client previously admitted to the hospital two weeks ago for hypertension. The nurse notes that, upon discharge, the client received a prescription for amlodipine (five mg PO daily) and was advised to lose weight. The nurse should be concerned when noting which of the following during the visit? A. The client states that they have already enrolled themself at a gym and are receiving dietary counseling from a nutritionist. B. The nurse notes the client is drinking grapefruit juice. C. The client asks the nurse multiple questions about following their treatment regimen. D. The client stated that they had an episode of dizziness a day after discharge but has been fine since.

Choices A, B, C, and E are correct. EVD is highly contagious, and despite a vaccine being available, it has a high mortality rate. For any infectious outbreak, visitation should be restricted. This also includes non-essential healthcare workers. When caring for a client with a pathogen like Ebola, logging the entry and exit of healthcare providers would be helpful to contact trace for any potential exposures. Bleach is the cleaning agent of choice, and bleach sprays and wipes should be readily available. Having a trained observer while staff don and doff PPE has effectively prevented accidental exposures.

The emergency department (ED) charge nurse is preparing for a surge of clients diagnosed with Ebola virus disease (EVD). The nurse should plan to take which action? Select all that apply. - Implement visitor restrictions for affected clients - Log entry and exit of all healthcare workers who provide care - Ensure that bleach disinfectant wipes are available in each room - Provide reusable personal protective equipment - Have an observer for donning and doffing of personal protective equipment

- Mycoplasma pneumonia - Haemophilus influenzae, type b pneumonia - Epiglottitis, due to Haemophilus influenzae type b

The infection control nurse is conducting rounds on the nursing unit and should ensure which conditions are isolated with droplet precautions? Select all that apply. Clostridium difficile Cryptococcosis meningitis Mycoplasma pneumonia Haemophilus influenzae, type b pneumonia Rheumatic fever Varicella Zoster Scabies Epiglottitis, due to Haemophilus influenzae type b Infectious mononucleosis Rotavirus gastroenteritis

Choice D is correct. When moisture comes into contact with a sterile dressing, this causes contamination. The nurse should prepare to change the dressing using medical asepsis to remove the old dressing and surgical asepsis to apply the new dressing.

The nurse assesses a client's central venous catheter dressing, and it appears loose and wet. The nurse should take which action? A. Reinforce the dressing with paper tape B. Remove the dressing and the central vascular device C. Apply a clean occlusive dressing to the site D. Clean the site and apply a new sterile dressing

Choices A, B, and D are correct. Clients with dementia may experience a superimposed delirium (sundowning syndrome) which alters their cognition and behavior in the evening and overnight. Thus, it is appropriate for the nurse to round on the client more frequently, which will help the nurse assess the client for potential injury and allow for enhanced observation. Individuals who experience delirium are at risk for injury because they may be impulsive and lack appropriate judgment. This and placing the client closer to the nurses' station is helpful because this would facilitate more enhanced observation. The client's impulsivity and impaired judgment raises the client's fall risk, and an electronic bed alarm would be helpful.

The nurse cares for a client with advanced dementia who exhibits confusion during the evening and overnight hours. The nurse should implement which interventions into the client's plan of care? Select all that apply. - Round on the client more frequently - Place client near the nurses' station - Obtain a prescription for a benzodiazepine - Implement an electronic bed alarm - Keep the television on overnight to keep the client distracted

Choices A, C, and D are correct. These observations require follow-up because they are unsafe. The client's armband should not be the sole source of client identification but rather collateral information. It should be attached to the client, not a bedside table or bed. Specimen tubes should never be prelabeled. Specimen collection requires appropriate labeling and client verification when obtaining the specimen. A room number cannot be used as a reliable client identifier.

The nurse conducts safety rounds within the nursing unit. Which observation requires follow-up? Select all that apply. - The client's armband was affixed to the bedside table. - The client's telephone number and name were used as identifiers. - Multiple blood specimen tubes are labeled before specimen collection. - A room number is used as an identifier during medication administration. - Verifies client's name, date of birth, consent, site, and procedure during a time out process.

Choice B is correct. Droplet precautions are indicated for patients with Mycoplasma pneumonia. Droplet precautions include wearing a surgical mask when within 3 feet of the patient, proper hand hygiene, and placement in a private room or with a cohort of patients. Other examples where droplet precautions are indicated include Pertussis, Influenza, Diphtheria, and invasive Neisseria meningitides. There are three types of transmission-based precautions: The model used depends on the mode of transmission of a specific disease. Airborne Contact Droplet

The nurse is admitting a 72-year-old patient hospitalized for a medical diagnosis of Mycoplasma pneumonia. Which transmission-based precaution is necessary? A. Private room with negative pressure airflow B. Wearing a surgical mask within 3 feet of the patient C. Wearing gloves when in contact with the patient D. HEPA filtration for incoming air

Choice A is correct. Cryptococcosis pneumonia is a fungal infection not transmitted from human to human. Rather, this infection is opportunistic for individuals who are significantly immunocompromised. Standard precautions are necessary, which involve appropriate hand hygiene.

The nurse is admitting a client who has cryptococcosis pneumonia. Which of the following actions would be appropriate for the nurse to take? A. Ensure a hand sanitizing station is near the client's room. B. Wear a surgical mask when working within three feet of the client. C. Keep the door to the client's room always closed. D. Place the client in a private room with monitored negative airflow.

Choices A, B, and D are correct. Risk factors for falls include age over 65 years, documented history of falls, postural hypotension, and unfamiliar environment. Falls among older adults are the most common cause of hospital admissions for trauma.

The nurse is performing a fall risk assessment on a group of clients. It would be appropriate for the nurse to identify the client at risk for falls who Select all that apply. older than 65 years of age. has a history of two previous falls taking oral antibiotics. experiences postural hypotension. experiencing chemotherapy-related nausea.

Choice A is correct. Varicella (chickenpox) requires contact and airborne precautions. A key part of contact precautions is ensuring the client has dedicated (or disposable) client care equipment. This is an intervention that will prevent the pathogen from infecting other individuals.

The nurse is caring for a child admitted with varicella (chickenpox). Which of the following actions should the nurse take? A. Have a designated blood pressure cuff in the client's room. B. Remove all gowns and gloves after exiting the client's room. C. Clean commonly touched surfaces with warm, soapy water. D. Wear a protective gown when transporting the client to other departments.

The nurse is caring for a child with varicella zoster. The nurse should implement which transmission-based precautions? A. Droplet precautions B. Airborne and contact precautions C. Contact and droplet precautions D. Contact precautions

The nurse is caring for a child with varicella zoster. The nurse should implement which transmission-based precautions? A. Droplet precautions B. Airborne and contact precautions C. Contact and droplet precautions D. Contact precautions

Choices A, B, D, and E are correct. Assessing a client in soft wrist restraints should occur at a minimum of every two hours (or per facility policy). Pertinent assessments should include the client's behavioral status, skin integrity, neurovascular status (pulses, capillary refill), and the continued need for the restraint.

The nurse is caring for a client in bilateral soft wrist restraints. The nurse should assess the client's Select all that apply. behavioral status. skin integrity. bowel sounds. neurovascular status. need for the restraint.

Choices B and C are correct. The client's blood glucose has been above 250 mg/dL for three consecutive readings and the physician needs to be notified. In addition, the sliding scale prescribes six units of insulin based on the 17:30 CBG result.

The nurse is caring for a client who has a prescribed regular insulin sliding scale. At 0800, the client's capillary blood glucose (CBG) was 258 mg/dl(70-110 mg/dL). At 1215 the CBG was 288 mg/dl(70-110 mg/dL). At 1730 the CBG was 254 mg/dl(70-110 mg/dL). The nurse should do which of the following at 1730? See the table below. Select all that apply.

Choice B is correct. Fans should be removed from a room for a client with droplet or airborne precautions. Fans may propel the transmission of a pathogen. A client with pulmonary tuberculosis should be isolated using airborne precautions.

The nurse is caring for a client who has pulmonary tuberculosis (TB). Which infection control measure should the nurse implement? A. Restrict visitors who are pregnant B. Remove any portable fans in the room C. Wear a dosimeter badge during client care D. Place the client further away from the nursing station

Choices A and E are correct. A gown and gloves should be used when coming into contact with an MRSA wound. This prevents secretions from the wound from infecting the nurse.

The nurse is caring for a client with a sacral wound infected with Methicillin-resistant staphylococcus aureus. Which personal protective equipment (PPE) is necessary to care for this client? Select all that apply. Gloves N95 respirator Surgical Mask Goggles Gown

Choice A is correct. Infectious mononucleosis (IM) requires standard precautions. Disease transmission is spread by prolonged exposure to human saliva and is difficult to spread. Often IM is referred to as the 'kissing disease' because prolonged kissing may transmit this pathogen. It is appropriate to place a client with HIV in the same room as a client with IM. HIV requires standard precautions.

The nurse is caring for a client with human immunodeficiency virus (HIV). It would be appropriate for the nurse to assign the client to a room with the client diagnosed with A. infectious mononucleosis. B. mycoplasma pneumonia. C. gastroenteritis (rotavirus). D. mumps (infectious parotitis).

Choice D is correct. For a client on either airborne or droplet precautions, the nurse should not allow (and remove) any portable fans, as these may propel pathogens and assist in disease transmission. If the client has a fever, nonpharmacological treatment options such as a cool compress or a tepid bath should be used. Pulmonary tuberculosis requires airborne precautions.

The nurse is caring for a client with pulmonary tuberculosis. Which action should the nurse take? A. Place a box of disposable respirators inside the client's room B. Remove alcohol-based sanitizers from the client's room C. Assign the client to a private room with a positive airflow D. Remove the portable fan from the client's bedside table

Choice A is correct. Appropriate hand hygiene is the most effective measure the nurse can take to reduce the transmission of disease-causing pathogens. The nurse should perform hand hygiene after toileting, before, during, and after preparing food, before and after client care, and if the hands are visibly soiled. Alcohol-based hand rubs (ABHRs) may be used as long as the hands are not visibly soiled and if the client does not have conditions that resist ABHRs, such as C. diff, norovirus, or rotavirus.

The nurse is caring for assigned clients. Which essential infection control measure should the nurse take? A. Perform hand hygiene before, after, and between providing direct client care B. Wear gloves while providing client care C. Cleanse equipment such as thermometers or stethoscopes between client care D. Maintain a distance of 3 feet away from clients who are coughing

Choices B, C, and D are correct. Falls and injuries can be reduced by ensuring the call button are accessible and within easy reach for the client. The call light can be clipped or secured when the client is in bed to prevent falling out of reach. Falls also may be reduced by placing fall risk bands on clients who are at risk. This will alert staff to the client's risk of falling. Setting the bed to the lowest position would reduce the risk of injury in the event of a fall because such positioning keeps the client at a closer distance to the floor.

The nurse is caring for several clients in a long-term care facility. Which interventions should the nurse implement to reduce the risk of injury from falls? Select all that apply. - Avoid administering ibuprofen at night - Secure the call button to the side of the bed - Keep the bed in the lowest position - Place fall risk bands on clients at risk of falling - Reposition clients off of bony prominences every two hours

Choice A is correct. Hand hygiene is a crucial component of standard precautions. It is the most critical measure to prevent the spread of infections among clients. Usually, hand hygiene may be performed either by washing hands with soap and water or by using an alcohol-based sanitizer. However, in certain situations, it is required that hand hygiene is performed only by washing hands with soap and water. These situations include scenarios when the hands are visibly soiled or cases of diarrheal illness from spore-forming Clostridium difficle

The nurse is conducting a staff conference regarding standard precautions. It would be correct for the nurse to state that hand washing with soap and water is required when A. hands are visibly soiled. B. collecting vital signs (VS). C. performing range of motion exercises. D. inputting data into the eletronic medical record (EMR).

Choices A and B are correct. Dressing changes of central lines requires a sterile technique. Central lines include ports, peripherally inserted central catheters and intrajugular access. An indwelling urinary catheter insertion requires a sterile technique to prevent urinary infection.

The nurse is conducting an in-service for nursing students. It would be appropriate for the nurse to state which of the following procedures requires a sterile technique? Select all that apply. - Changing the dressing for a central line - Inserting an indwelling urinary catheter - Removing a peripheral vascular access device - Suctioning an endotracheal tube with in-line suction - Inserting a nasogastric tube (NGT)

Choice B is correct. Pulmonary TB is only spread via aerosolized droplets. TB is not spread via contact with surfaces, handshakes, sitting on toilet seats, or dishes. The essential teaching point to a client with pulmonary TB is to instruct the client to exercise respiratory etiquette, such as covering your mouth with a tissue when you cough or laugh. The tissues should be disposed of in a trash can. The client is at the highest risk of transmitting TB while symptomatic. Once the client begins antitubercular medications, the risk of transmission drops after two to three weeks.

The nurse is discharging a client home who has pulmonary tuberculosis. To prevent disease transmission of the client's infection to others, the nurse should recommend that A. common household surfaces get disinfected with a bleach solution. B. your mouth should be covered with a tissue when you cough or laugh and dispose of it in a trash receptacle. C. hand hygiene should be performed frequently with soap and water. D. meals be served on disposable dishes and immediately discarded using gloves.

Choices A, B, and F are correct. Diphtheria, rubella, Haemophilus influenza, type b, all require droplet precautions. The personal protective equipment (PPE) necessary for droplet precautions is a surgical mask.

The nurse is discussing infection control practices in the nursing unit. Which client requires droplet precautions? A client with Select all that apply. - diagnosed with rubella. - a new diagnosis of diphtheria. - receiving chemotherapy via an implanted port. - pulmonary tuberculosis receiving nebulizer treatments. - a skin abscess that tested positive for Klebsiella. - Haemophilus influenzae, type b

Choices A and C are correct. Conditions requiring airborne precautions include pulmonary tuberculosis and rubeola.

The nurse is discussing infection control with a group of nursing students. It would be correct to state that airborne precautions are used for which condition? Select all that apply. Pulmonary tuberculosis Pertussis Rubeola Hepatitis A Rubella

Choices A and C are correct. Conditions requiring droplet precautions include influenza and pertussis.

The nurse is discussing infection control with a group of nursing students. It would be correct to state that droplet precautions are used for which condition? Select all that apply. Influenza Viral meningitis Pertussis Hepatitis C Lyme disease

Choice C is correct. Pediculosis (also known as head lice) requires contact precautions. Pediculosis requires contact isolation until 24 hours after initiation of effective therapy. Choice E is correct. Scabies is a parasite that may cause intense itching and may be found around the hands and wrists. Scabies require contact isolation until 24 hours after initiation of effective therapy. Choice F is correct. Clostridium difficle is a spore-forming bacteria that causes diarrhea. Contact precautions are necessary; commonly touched surfaces should be disinfected with bleach because the spore may resist standard cleaning agents.

The nurse is discussing infection control with a group of nursing students. Which conditions require contact precautions? Select all that apply. Rubeola Psoriasis Pediculosis Rubella Scabies Clostridium difficle

Choices A, B, and C are correct. A mass casualty is any event that demands more medical resources than what may be provided. A mass shooting or pandemic may qualify as a mass casualty event (Choice A). When this event occurs, the staffing assignment needs to change to expand the number of clients a nurse cares for. Nurses from different departments may need to be floated to the emergency department to assist with client management (Choice B). Many local organizations must collaborate to handle a mass causality incident, including public health services, emergency medical services, and local government (Choice C).

The nurse is discussing mass casualties with a group of nursing students. Which statement by the student would indicate effective understanding? Select all that apply. - "Mass casualties are events that overwhelm local medical capabilities." - "When a mass casualty occurs, there is a need to increase the staff at the hospital." - "Many local agencies will collaborate to handle a mass casualty situation." - "An example of a mass casualty event is a fight between visitors in the intensive care unit." - "Staff preferences for client assignments should prioritize over client needs."

Choices B and E are correct. Proper visitor identification is essential for maintaining hospital security. This enables rapid identification and creates a log of all visitors within the facility. Disaster drills should be conducted to ensure that staff are competent with procedures related to specific threats such as mass bioterrorism, active shooter training, or fire.

The nurse is participating on a committee changing the hospital security plan. Which of the following statements by the nurse would be appropriate to make? Select all that apply. - Open visitation should be implemented in the newborn nursery. - Visitors should always wear a badge while in the hospital - Oral temperatures should be obtained for all visitors - Hand sanitizing stations should be offered throughout the facility - Disaster drills should be conducted to ensure staff competency

Choice A is correct. Although the influenza vaccine will not prevent 100% of the cases, it will help prevent or decrease symptoms in 70 to 80% of cases. If the client does get influenza, the severity of the symptoms will be diminished thanks to the vaccine. Choice B is correct. Those who are pregnant may receive the inactivated influenza vaccine (IIV). It is the Live attenuated influenza vaccine (LAIV) that should not be administered to those who are pregnant. The LAIV is licensed for ages 2-49. Choice C is correct. Penicillin allergy is not a contraindication to the administration of the influenza vaccine. Very few contraindications exist to receiving the influenza vaccine. Some contraindications include children younger than six months of age, individuals with a previous severe reaction to a prior influenza vaccine, and a history of Guillain-Barré syndrome. Egg allergy is not a contraindication to this vaccine being administered.

The nurse is educating a client about the inactivated influenza vaccine (IIV). The nurse should plan to teach the client that Select all that apply. - the IIV effectively prevents influenza or decreases the disease's severity. - pregnant women can receive this vaccine. - you may receive this vaccine if you are allergic to penicillin. - the IIV contains a live virus. - the vaccine is administered to newborns following delivery.

Apply the gown Secure the mask Apply the goggles/face shield Don gloves

The nurse is instructing a nursing student on the correct application of personal protective equipment (PPE). The nurse should tell the student to apply the PPE in what order? Place each action in the correct order. Secure the mask Don gloves Apply the goggles/face shield Apply the gown

Choices A, C, D, and E are all correct. A is correct. Excluding the family from the interview allows the client to freely express their feelings, concerns, and experiences without potential influence or interference from family members. It promotes client autonomy and empowers the client to share information openly. C is correct. Domestic violence is a sensitive topic, and ensuring a safe and confidential environment is crucial for the client's well-being. Excluding the family helps maintain privacy and confidentiality, fostering trust and allowing clients to feel more comfortable sharing their experiences. D is correct. In situations of domestic violence, the presence of family members during the interview may create a power dynamic that could intimidate or coerce the client. The nurse can help ensure the client's safety and emotional well-being by excluding the family. E is correct. Excluding the family from the interview reduces the risk of retaliation or harm if the client's disclosures reach the perpetrator. This measure prioritizes the client's safety and promotes their trust in the healthcare professional.

The nurse is interviewing a 25-year-old female client who recently experienced domestic violence. What is the rationale for excluding the family from the interview to ensure a safe and confidential environment? Select all that apply. Promote client autonomy Maintain family dynamics and support Maintains privacy and confidentiality Prevent potential intimidation or coercion Minimize the risk of retribution

Choice A is correct. This action requires follow-up because reaching over the sterile field may cause contamination.

The nurse is observing a student prepare to perform a sterile procedure. Which action by the student would require follow-up? The student A. reaches over the sterile field to grab sterile gloves. B. establishes the sterile field on a dry surface. C. uses slow movements when setting up sterile drapes. D. keeps the sterile field at their waist level.

Choices C and E are correct. These observations are inappropriate and require follow-up. The door should be closed in airborne isolation precautions, not droplet precautions. A client with rubella should be placed on droplet precautions. The minimum PPE required for droplet precautions is a surgical mask. Legionnaires' disease is not transmitted person-to-person but rather through infected water or soil. This bacterium requires standard precautions.

The nurse is observing infection control practices in the nursing unit. Which of the following findings require follow-up? A client with Select all that apply. - H. pylori placed on standard precautions. - rotavirus provided a disposable blood pressure cuff. - rubella and their door is kept closed. - influenza ambulating in the hall with a surgical mask. - Legionnaires' disease placed on contact precautions.

Choices A, B, and E are correct. These observations require follow-up because they are inappropriate during hand hygiene. After hand hygiene with soap and water, hands should be dried from the cleanest (the fingers) to the least clean (the wrists) with a paper towel or single-use cloth. This avoids contamination. Touching the inside of the sink would contaminate the hands, and the process would need to start over. Water should not splash on the uniform as microorganisms grow with moisture.

The nurse is observing staff perform hand hygiene using antiseptic soap and water. Which observation by the nurse requires follow-up? Select all that apply. - Dries hands thoroughly from wrist to fingers - Touches the inside of the sink - Hands and forearms are lower than elbows during washing - Rinses hands and wrists by keeping hands down and elbows up - Water splashes on the uniform

Choice B is correct. When caring for a client who has AIDS, the nurse should maintain standard precautions. Applying PPE such as a gown, pair of gloves, and mask would be inappropriate. Standard precautions require appropriate hand hygiene and other PPE as needed.

The nurse is obtaining vital signs for a client who has acquired immune deficiency syndrome (AIDS). Prior to entering the room, the nurse should do which of the following? A. Wear gloves and a gown. B. Perform hand hygiene. C. Review the client's viral load. D. Obtain a disposable stethoscope.

Choice A is correct. Utilizing more bedside commodes for older adults may reduce falls because it shortens the distance a client needs to travel to the bathroom. Bedside commodes are especially effective for those receiving medications such as diuretics and undergoing bowel prep. Thus, a bedside commode is an effective intervention to reduce falls for the older adult.

The nurse is participating in a committee reviewing strategies to reduce falls in the older adult. Which of the following recommendations by the nurse would be appropriate to make? A. Increase the number of bedside commodes in the client rooms B. Provide more hand sanitizer stations in high traffic areas C. Standardize administration times of diuretics to the evening hours D. Implement a bedside handoff reporting process for nursing staff

Choice C is correct. Furniture should be arranged so that there are clear paths, free of rugs, cords, or other obstacles. It is unsafe for the client to use furniture for support during walking. The nurse should discuss the risks associated with this action and evaluate the client's need for a mobility aid such as a walker or cane.

The nurse is performing a home safety assessment for an older adult. Which of the following client statements would require follow-up by the nurse? A. "I will have grab bars installed in the bathroom." B. "I placed a nonskid mat in my shower." C. "My furniture is arranged so I can hold onto something if I need it." D. "I secured my electrical cords against the wall behind furniture."

Choices C, D, and E are correct. Refugees are vulnerable because of their socioeconomic challenges in getting healthcare (lack of transportation, health insurance, and financial resources). Standard health screenings are performed for all refugees to recognize and prevent disease transmission. Routine screening includes viral hepatitis, intestinal parasites, sexually transmitted infections, mental health disorder (depression, suicide, post-traumatic stress disorder), and pulmonary tuberculosis.

The nurse is performing health screenings on a group of refugees. The nurse plans on performing which screening for this population group? Select all that apply. Hypothyroidism Attention deficit hyperactivity disorder (ADHD) Pulmonary tuberculosis Intestinal parasites Viral hepatitis

Choices A, B, C, and E are correct. These statements are true and should be included in the conference. Mittens are not considered restraints if they are untethered, and the client may be able to remove the mitt. Elbow restraints make removing a medical device near the face or neck difficult. It does not impede the removal of abdominal or urinary medical devices. Belt restraints should be applied over a client's clothing and secured to the bedframe. Significant impairment to a client's skin may result if the belt is directly applied over the skin. Restraints must be removed every two hours to allow for a range of motion. However, if the client is violent, each restraint should be removed once at a time versus both, which allows the client to elope or inflict further violence.

The nurse is planning a staff development conference about restraints. Which of the following information should the nurse include? Select all that apply. - Mittens are not restraints if untethered and the client is physically able to remove the mitt. - Elbow restraints may allow a client to remove abdominal or urinary medical devices. - Soft wrist restraints should be removed one at a time if a client is violent. - Belt restraints may be prescribed on an as-needed basis. - Belt restraints should be applied over a client's clothing garments.

Choice B is correct. The primary way HCV is transmitted is through blood exposure which a needle stick may trigger. The nurse should discuss safety regarding the disposal of needles, such as the importance of not recapping needles.

The nurse is planning a staff development conference about ways to prevent the transmission of the hepatitis C virus to healthcare workers. It would be appropriate for the nurse to cover which topic? A. How to obtain the HCV vaccine B. How to dispose of sharps safely C. How to dispose of urine and feces for those with HCV D. Isolation precautions for individuals with HCV

- Apply a tourniquet and palpate a vein for insertion - Clean the skin with approved solution - Stabilize the vein below the insertion site (digital traction) - Puncture the skin and vein with the stylet - Observe for blood return and advance the catheter - Apply pressure above the insertion site and connect the IV tubing - Tape and secure the IV site

The nurse is preparing to insert a peripheral vascular access device (PVD). Which steps should the nurse take to insert a PVD? Place each action in the correct order. - Apply a tourniquet and palpate a vein for insertion - Clean the skin with approved solution - Tape and secure the IV site - Stabilize the vein below the insertion site (digital traction) - Puncture the skin and vein with the stylet - Apply pressure above the insertion site and connect the IV tubing - Observe for blood return and advance the catheter

Choices B, C, and E are correct. When varicella zoster is disseminated, it can be transmitted through airborne means and by direct contact with the lesions. The isolation required is contact + airborne. This means the nurse should wear an N95 respirator, high-efficiency particulate air filter respirator, gown, and gloves. Herpes zoster, also known as shingles, is caused by the reactivation of the varicella-zoster virus (VZV), the same virus that causes varicella (chickenpox). Primary infection with VZV causes varicella. Once the illness resolves, the virus remains latent in the dorsal root ganglia. VZV can be reactive later in a person's life and create a painful, maculopapular rash called herpes zoster. When herpes zoster (varicella-zoster) (shingles) is localized and can be covered, standard precautions are implemented until all of the lesions have crusted over. When herpes zoster (varicella-zoster) (shingles) is disseminated, airborne + contact precautions are implemented for the duration of the illness.

The nurse is preparing to provide care for a client with disseminated herpes zoster. The nurse plans to don which personal protective equipment (PPE)? Select all that apply. goggles gown gloves shoe covers n95 respirator Surgical face mask

Choices A, B, C, and E are correct. To prevent contamination, packages should be opened away from the body (reaching over the sterile field causes contamination). If anything is contaminated, it should be removed immediately and discarded. Contaminated objects should be kept away from the sterile field and the sterile field (and its objects) should be kept above the waist. The nurse should avoid touching the sterile field as much as possible but is permitted to touch the outer one-inch (2.5 cm) edge of the field, if necessary.

The nurse is reviewing a newly hired nurse's understanding of sterile technique. Which statement, if made by the newly hired nurse, would indicate effective understanding? Select all that apply. - "I should open sterile packages away from my body." - "If the sterile field gets contaminated, I should dispose of everything and start over." - "One inch (2.5 cm) border around a sterile drape can be touched with clean fingers." - "I should apply sterile gloves on my non-dominant hand first." - "An object placed below my waist is considered contaminated."

Choices A, C, and E are correct. These statements are false and require follow-up. Incident (sometimes termed occurrence or event) reporting is required when any type of activity deviates from the norm. This could include a fall, medication error, elopement, unplanned transfer of care, client complaint, or a delay in care. It is highly recommended that the event be reported after it occurs to ensure accuracy; however, event reporting should be completed as soon as possible, including the next day. No rule exists stating that reports must be completed within one hour after the actual event. Incidents involving visitors such as a fall, misconduct, complaint, or injury should be reported.

The nurse is teaching a group of students about incident reports. Which of the following statements, if made by the student, would require further teaching? Select all that apply. - "Reporting can only be completed if it is within one hour after the event." - "Witnesses to an incident should be mentioned in the report." - "A client eloping does not require an incident report." - "A slip and fall by a client should be reported." - "Incidents involving visitors do not have to be reported."

Choices B, C, and D are correct. Medications that may hasten the risk for falls and included benzodiazepines such as alprazolam. This medication causes drowsiness and may impair judgment. Bumetanide is a loop diuretic; this medication may cause a client to experience orthostatic hypotension and the urgency to use the bathroom. Both of which pose a fall hazard. Verapamil is a calcium channel blocker and is utilized in the management of migraines and hypertension. This medication causes vasodilation; therefore, it will allow the client to become orthostatic if they do not shift positions slowly.

The nurse is teaching a group of students about medications and fall prevention. The nurse would be correct to identify which of the following medications can increase the risk for falls? Select all that apply. Naproxen Alprazolam Bumetanide Verapamil Allopurinol Thiamine

Choices A, D, and E are correct. Anytime the nurse or unlicensed assistive personnel (UAP) engages directly with the client, two identifiers (name and date of birth) should be asked. This prevents misidentification and mitigates errors related to care delivery. Providing a meal tray will require the identifiers because diets vary by client and are prescribed by the primary healthcare provider (PHCP). Obtaining vital signs requires the two identifiers so the nurse (or UAP) may accurately record these vital signs. Finally, providing range of motion requires two identifiers as it is a task directly involving the client.

The nurse is teaching a group of unlicensed assistive personnel (UAPs) concepts of client identification. Which situation would require two client identifiers? Select all that apply. Providing a meal tray Changing bed linens Replacing a suction cannister Obtaining vital signs Providing range of motion exercises

Choices B and D are correct. Teaching children about signs of fire is key. One of the critical aspects is teaching children about what the smoke (or carbon monoxide) detector sounds like so recognition is appropriately instilled. Practice drills should be performed twice a year in the event of a fire. These practice drills will help children escape and find a predetermined area in the neighborhood where the family will meet after escaping the house from a fire. The smoke detector batteries should be replaced twice a year.

The nurse is teaching parents about fire safety in the home. Which of the following recommendations should the nurse make? Select all that apply. - Use smoke detectors instead of carbon monoxide detectors - Teach your child what the smoke detector sounds like and what to do when one is heard - Teach children how to light a candle in the event of power failure - Practice escaping from your home at least twice a year - Ensure that electrical wiring is under rugs, not above them - If a house fire occurs, call emergency services before evacuating

Choice C is correct. One key concept to remember when dealing with alternative therapies is that natural does not always mean "better or safe." Some herbal products contain ingredients that may interact with prescription drugs. For example, patients taking medications with potentially dangerous adverse effects, such as insulin, warfarin, or digoxin, should be warned to never take dietary supplements without first discussing their needs with a physician. Complementary and alternative medicine (CAM) is comprised of an incredibly diverse set of therapies and healing systems. CAM is considered to be outside the mainstream of healthcare. From a therapeutic perspective, much of the value of CAM therapies is their ability to reduce the need for medications.

The nurse needs to assess the use of complementary and alternative medicine (CAM) because: A. Patients should be warned that most CAM therapies are potentially dangerous B. Additional treatment may not be needed if the patient is using CAM C. CAM therapy could interact with prescription and over-the-counter medications D. Most CAM therapies are essentially ineffective

Choice B is correct. This action is not appropriate and requires follow-up. A client in physical restraints should not be positioned prone, which may lead to suffocation. Additionally, a client should not be positioned supine because this makes the client feel vulnerable.

The nurse observes a newly hired nurse apply bilateral soft-wrist restraints to a client. Which action by the newly hired nurse requires follow-up? A. Secures the restraint to the frame of the bed B. Repositions the client from semi-Fowlers to prone. C. Provides easy access to the quick release buckle D. Assesses the radial pulse every two hours

Choice C is correct. The safety of the client is the highest priority in any emergency situation. Removing the client from the room is the first and most crucial action to protect them from potential harm, such as electrical shock or fire-related injuries.

The nurse observes sparks fly from a client's bathroom light. Which action should the nurse take first? A. Obtain a fire extinguisher B. Close the bathroom door C. Remove the client from the room D. Activate the fire alarm

Choices C and D are correct. Telephone and verbal orders are significant sources of errors. Different dialects, mispronunciation of medications, and accents may skew a medication order. To promote accuracy, the nurse should spell out the numbers; for example, if the physician orders fifty milligrams of metoprolol, the nurse should repeat back five, zero to ensure fifty was the accurate dose. These orders (verbal and telephone) should be limited to emergencies.

The nurse participates in a task force to reduce errors related to telephone and verbal orders. The nurse should recommend that Select all that apply. - unlicensed assistive personnel (UAP) can take a physician's telephone prescription. - use more abbreviations when transcribing a physician's order. - when repeating an order back to the physician, spell out numbers. - verbal and telephone orders be limited to emergency situations. - transcribing telephone and verbal orders be delayed until a second nurse can review the order.

The findings that require intervention by the nurse include the following - Multiple glass tables in the living room: multiple glass tables are concerning because the client may fall and sustain a serious injury during a seizure. Tables should be limited; if used, the edges should be covered with padded covers to reduce head injury. Multiple feather pillows are present on the bed: seizure-safe pillows are available for sale as they reduce asphyxiation. Seizure-safe pillows should be used; the fewer pillows, the better to reduce the risk of asphyxiation. Wall-to-wall carpeting was removed and replaced with scattered rugs on hardwood flooring: wall-to-wall carpeting is highly recommended because if the client falls while having a seizure, this will reduce the injury compared to a hardwood floor. Kitchen knives were readily accessible: Knives should not be used because a serious injury can be sustained if a seizure occurs while using a knife. A food processor should be used instead of knives. Locks on the bathroom door: Locks should not be on the door because if the client has a seizure in the bathroom, immediate access would be hampered by the lock. Instead, the client should have a placar

The nurse performs a home safety survey for an individual with epilepsy Click to specify the findings that require intervention by the nurse Living area and bedroom Multiple glass tables in the living room Multiple feather pillows present on the bed Relocated bedroom from the second floor to the first floor Padded covers on the edges of countertops Wall-to-wall carpeting was removed and replaced with scattered rugs on hardwood flooring Kitchen Kitchen knives were readily accessible Client reports using the microwave instead of the stove Bathroom Rubber mats in the bathtub Shower chair with hand-held shower nozzle present Locks on the bathroom door

Choice C is correct. Haemophilus influenzae, type b Meningi requires droplet precautions. Droplet precautions require the nurse to don a surgical mask upon entry to the client's room. Cohorting with droplet precautions is permitted as long as the other individual has the same pathogen. Clients who require transport or want to ambulate outside their room should don a surgical mask.

The nurse plans care for a client admitted with Haemophilus influenzae, type b Meningitis. When caring for this client, the nurse should gather which appropriate personnel protective equipment (PPE)? A. Boot (shoe) covers B. Face shield C. Surgical mask D. Gown

systemic infection; washing hands frequently; collecting blood cultures

The nurse recognizes that this client is at increased risk for developing ____ therefore, the nurse should implement neutropenic precautions which involves ____ Considering the client has a fever, the nurse anticipates an order for ____

-Obtain a prescription for metronidazole -Educate the client to wash surfaces at home with bleach -Remove the alcohol-based sanitizers from the room -Encourage the intake of by mouth (PO) fluids -Review hand hygiene measures with the client

The nurse reviews the nurses' notes, orders, current medications, and laboratory data. Based on the clinical data, select five (5) nursing interventions the nurse should implement. - Obtain a prescription for metronidazole - Place a droplet precautions sign outside the room - Educate the client to wash surfaces at home with bleach - Remove the alcohol-based sanitizers from the room - Request a prescription for a cleansing enema - Encourage the intake of by mouth (PO) fluids - Review hand hygiene measures with the client

Choice D is correct. Unfamiliar surroundings is a significant risk factor for falls, especially in the elderly. The hospitalized client may become confused or bump into furniture, which could result in a fall. Along with unfamiliarly surroundings changes in routine, and the potential for medical conditions and medications that can affect balance and coordination are also reasons this client would be a high fall risk. . Age-related changes may affect the mobility and safety of older adults. For example, decreased muscle strength, reduced balance, and osteoporosis put older adults at risk for falls and fractures. For health promotion, the nurse assesses the musculoskeletal functioning of the older adult and identifies any risk factors that may contribute to falls or the ability of the older adult to perform ADLs. Health promotion interventions often include providing information about the risk factors for osteoporosis and the importance of adequate intake of calcium and vitamin D.

The nurse working with geriatric clients understands that falls are more likely to occur in elderly clients who are: A. Living on disability insurance B. In their 80s C. Living in their own home D. Hospitalized

Choice B is correct. The nursing diagnosis "at-risk for an alteration in vascular perfusion" is most applicable to this client, as the recently casted extremity following the greenstick fracture places this client at risk for decreased tissue and vascular perfusion, primarily compartment syndrome. Compartment syndrome is always a concern for a client with a newly placed cast. In compartment syndrome, tissue pressure (often due to swelling) occurs within a confined compartment space (enclosed within the cast), leading to restricted blood flow and, eventually, ischemia. Compartment syndrome is always considered a medical emergency and requires prompt medical intervention. Failure to intervene quickly can result in ischemia, possibly leading to irreversible damage to the tissue(s).

The nursing diagnosis "at-risk for insufficient vascular perfusion" would most apply to which of the following clients? A. An adolescent client undergoing an expected maturational growth spurt B. A 6-year-old pediatric client with a leg recently placed in a cast following a greenstick fracture C. A 76-year-old female client with urinary and fecal incontinence D. A 42-year-old male client who recently sprained his ankle while playing basketball and wrapped the affected ankle in an elastic bandage

Choice C is correct. This is a true statement. Twisting while lifting an object will increase the likelihood of injury because twisting alters the individual's balance.

The occupational health nurse is conducting an in-service on reducing back injuries. Which of the following statements, if made by a participant, would indicate a correct understanding of the conference? A. "I should keep my legs straight while lifting." B. "Heavy objects should be held away from my body." C. "I shouldn't twist while lifting an object." D. "I should keep a narrow base of support."

Choice A is correct. Appropriate body mechanics are crucial to preventing injuries. Since most documentation is done electronically, ergonomics while using the computer is crucial. When sitting in a chair, the feet should be firmly on the ground to prevent stress on the lower back. The knees should be at the level of the hips or slightly lower. Choice D is correct. When picking objects off the ground, the individual should squat and not bend over. Squatting engages the thigh muscles to provide support as the object is lifted. Bending over would put stress on the lower back.

The occupational health nurse is teaching a group of unlicensed assistive personnel how to practice appropriate ergonomics. It would be appropriate for the nurse to recommend that Select all that apply. - your feet are firmly on the floor while you are sitting in a chair. - your feet are close together as you move or transfer a client. - heavy objects be held far away from your body to achieve balance. - you should squat to lift objects off of the ground. - your neck should be extended as you look at the computer monitor.

Choice B is correct. A patient with low blood pressure and tachycardia after a surgical procedure may be experiencing an illness. Blood loss results in lowered blood pressure and the heart rate increases to compensate.

The patient is experiencing post-operative tachycardia with low blood pressure. The nurse should be most concerned about which of the following surgical complications? A. The development of an infection B. Hemorrhage C. Wound dehiscence D. Hematoma

Choices A, B, and C are correct. The nurse should recommend addressing inadequate assessment because this is a significant risk factor for falls that may lead to client injury. The nurse can recommend a standardized fall risk assessment tool and monitor its execution. Communication failures between staff are a significant contributor to falls. The nurse should recommend addressing this by standardizing the handoff report and placing signals outside a client's room (a particular light, fall risk bands, or pictures outside of the client's room). The nurse can plausibly recommend the repair of dim environmental lighting, which is a risk factor for falls, especially when the client is ambulating within their room.

The quality improvement nurse plans an initiative to reduce risk factors for falls in the acute care environment. Which of the following risk factors should the nurse recommend be addressed? Select all that apply. inadequate client assessment communication failures dim lighting a client's medical history age of the client

Choice B is correct. The priority action is to immediately remove the wheelchair from use as soon as you become aware that the right brake on your client's wheelchair is not holding as strong as the left brake. Before any piece of medical equipment, including all assistive devices, is used, the piece of equipment must be inspected. When this type of irregularity is discovered, such as one wheelchair brake not holding as strong as the other, it is not the role or responsibility of the nurse to attempt to fix this issue, as the nurse is not trained nor competent to do so. Therefore, the priority action is for the nurse to immediately remove the piece of medical equipment from use and subsequently notify the appropriate person or department of the details of the concern according to facility policy.

The right brake on your client's wheelchair is not holding as strongly as the left brake. What is the priority action? A. Ask the client if this happened today. B. Immediately remove the wheelchair from use. C. Try to tighten the brake with a simple tool. D. Call the physical therapist for another wheelchair.

Choices A, B, and C are correct. A loss of electrical power to the facility, the sudden cessation of internal communication, and a toxic chemical spill in the lobby of the facility are all examples of domestic disasters. Other cases of civil emergencies include things like a fire, a bomb threat, a cyclone, a flood, a tornado or hurricane that affects the healthcare facility.

The unit charge nurse knows that which of the following are internal disasters? Select all that apply. - A loss of electrical power to the facility - The sudden cessation of internal communication - A toxic chemical spill in the lobby of the facility - A serious life threatening medication error - Train crash in neighboring town

Choice C is correct. Assessing if the patient is responsive is the primary concern of the nurse in this example.

Upon entering a client's room, the nurse finds the client lying on the floor. What is the first action the nurse should implement? A. Call for help to get the client back in bed B. Assist the client back to bed C. Establish if the client is responsive D. Ask the client what happened

Choice C is correct. Reducing the risk of healthcare-associated infections is the responsibility of every healthcare worker. Since the hands of healthcare workers are the most common means of transmission of infection from one client to another, the most effective method of preventing the spread of disease is to make supplies for hand hygiene readily available for staff to use. Following standard precautions for all patients is the easiest and most effective way of preventing the spread of disease.

Which of the following actions is most effective at reducing the incidence of health-care-associated infections? A. Screen all newly admitted clients for colonization or infection with MRSA. B. Develop policies that automatically start antibiotic therapy for clients colonized by multi-drug resistant organisms. C. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital. D. Require nursing staff to wear gowns to change wound dressings for all clients.

Choice C is correct. All staff members, including unlicensed assistive staff like nursing assistants, document and sign all of the care that they have personally provided. For example, the nursing assistants will document the vital signs that they have taken; the licensed practical nurses will document all of the treatments and medications that they have given to the patient, and the registered nurse will document nursing diagnoses and assessments that they have completed. There is an old saying among healthcare professionals that have been passed on to new generations. The saying is, "I don't care what you did; if you didn't document it, you didn't do it." Documentation is an essential part of patient care. A patient's complete medical record is a legal document. Proper documentation means 1. The person who provided care should document what care/treatment/medication was given and how the patient responded. 2. If care is delegated to another person, it should be noted to whom the responsibility was assigned; proper documentation AND follow-up should be done.

Which of the following healthcare providers are responsible for documenting care provided to a patient? A. The LPNs should document the care that they provided and the care that was given by unlicensed assistive staff. B. The registered nurse must document all of the care that is provided by the nursing assistants because they are accountable for all care. C. All staff members should document all of the care that they have provided. D. All staff should document all of the care that they have provided but since the registered nurse is the only independent practitioner, the RN signs it.

Choice B is correct. Throw rugs, furniture in walkways, and slippery footwear are all fall risks for patients.

Which of the following is the most accurate education for injury prevention in the home of elderly clients? A. Use the handrail when going up and down the stairs, ensure robes or pants are held up if flowy, and wear comfortable slippers. B. Remove all throw rugs, remove furniture from all pathways, and wear comfortable/non-skid footwear. C. Use solid chairs without armrests, keep walkways clear, and use cordless phones. D. Install raised toilet seats, ensure that all sinks have throw rugs to prevent slipping on water, and use grab bars in the shower/bathroom.

Choice C is correct. The nurse should have checked the patient's distal pulse immediately after the cardiac catheterization. Negligence and professional negligence are examples of unintentional torts that may occur in the health care setting. Negligence is misconduct or practice that is below the standard expected of an ordinary, reasonable, and prudent person. Such conduct places another person at risk for harm. Both nonmedical and professional individuals can be liable for negligent acts. Gross negligence involves an extreme lack of knowledge, skill, or decision-making that the person clearly should have known would put others at risk for harm. Malpractice is "professional negligence," that is, negligence that occurred while the person was performing as a professional. Malpractice applies to primary care providers, dentists, lawyers, and generally includes nurses. In some states, nurses cannot be sued for malpractice, only professional negligence. The terms malpractice and professional negligence are often used interchangeably. Six elements must be present for a case of nursing professional negligence to be proven: The nurse must have (or should have had) a relationship with the client

Which of the following situations is an example of negligence? A. The UAP (Unlicensed Assistive Personnel) fills a water basin with warm water while the patient with depression combs her hair. B. A nurse transcribes a new medication order: Questran powder 2 oz bid with wet food or one full glass of water. C. The nurse checks the distal pulses of a patient's legs two hours after they have returned from a cardiac catheterization. D. The nurse observes a UAP enter the room of a patient on contact precautions wearing gloves and a gown.

Choice B is correct. Carbon monoxide is a gas that is clear, odorless, and deadly. This invisible gas can build up in enclosed areas where engines, such as car engines, or kerosene heaters, are running idly.

Which of the following statements about carbon monoxide is accurate? A. Carbon monoxide is a gas that is gray in color and deadly. B. Carbon monoxide is a gas that is clear, odorless, and deadly. C. Carbon monoxide is a gas that is yellow and odorless. D. Carbon monoxide is a gas that smells like rotten eggs.

Choice B is correct. All healthcare facility members must have education and training relating to security in the facility.

Which of the following statements about security in healthcare environments is accurate? A. Healthcare facilities must have egress alarms on all doors, except client doors, to maintain security within the facility. B. All members of the healthcare facility must have education and training relating to security in the facility. C. Members of the healthcare facility who do not have clinical access do not need education and training relating to security in the facility. D. Members of the healthcare facility who have only clerical roles do not need education and training relating to security in the facility.

Choice C is correct. Varicella is a live virus. Currently, the available live attenuated viral vaccines are measles, mumps, rubella, vaccinia, varicella, zoster (which contains the same virus as varicella vaccine but in a much higher amount), yellow fever, rotavirus, and influenza (intranasal).

Which of the following vaccines contains a live virus? A. IPV B. DTaP C. Varicella D. Hepatitis B

Choice A is correct. You must thoroughly inspect and run the equipment before use to ensure that it is appropriately functioning BEFORE it is used. This inspection should include an overall assessment for frayed electrical cords and documented evidence that the piece of equipment has had the mandated preventive maintenance and safety inspections according to the facility's policies and procedure.

Your client has a stat order for a cooling or hypothermia blanket. After you call the appropriate department, the cooling blanket is delivered to your nursing care unit. What is the first thing you should do concerning this stat order? A. Inspect and run the equipment prior to use. B. Immediately use the cooling blanket for the client because it is a stat order. C. Ask the engineering department to perform preventive maintenance on it. D. Inspect the blanket for any frayed cords before to protect against fire.