HESI module 6 - 1/24/24

A home care nurse visits a client who lives in a small apartment to perform an admission assessment. During the home safety assessment, the client asks the nurse whether it is safe to use a space heater. What is the appropriate response by the nurse? "A space heater should never be used in an apartment." "A space heater can be used as long as it is kept at a low setting at all times." "A space heater can be used as long as it is kept in the bedroom at night in case a fire occurs." "A space heater can be used as long as it's placed at least 3 feet (1 meter) from anything that may ignite."

"A space heater can be used as long as it's placed at least 3 feet (1 meter) from anything that may ignite."

A post office employee with suspected skin anthrax asks the emergency department nurse whether the infection is curable. What is the appropriate response by the nurse? "You really need to ask your primary health care provider." "That's hard to say. We won't know for a week or two." "Antibiotic therapy is usually prescribed and will cure the infection." "It is not curable, but fortunately, unlike inhalation anthrax, it is not deadly."

"Antibiotic therapy is usually prescribed and will cure the infection."

A nurse prepares to teach a client with chronic vertigo about safety measures to help prevent exacerbation of signs/symptoms and injury. Which instructions should the nurse provide to the client? Select all that apply. "Change positions slowly." "Remove clutter from your home." "Use public transportation as much as possible." "Drive your car only if you're not feeling dizzy." "Turn your head slowly when someone speaks to you."

"Change positions slowly." "Remove clutter from your home."

The unit supervisor of an emergency department (ED) is called at home and told by an emergency department nurse who is on duty that an airplane crash has occurred and numerous casualties will be arriving at the ED. What should the initial response by the unit supervisor be? "Has the disaster plan been activated?" "Call as many nursing staff as you can to come in to work." "Make sure all of the rooms are well stocked with supplies." "Be sure that the nursing staff finds as many stretchers as they can."

"Has the disaster plan been activated?"

A nurse, assessing a client's readiness for discharge, is performing a home safety assessment to determine whether there are any environmental hazards in the home. Which of the following statements, if made by the client, would prompt the nurse to investigate further? Select all that apply. "I live in a single-story house." "I don't have any nightlights in the house." "I've removed the scatter rugs from the house." "I keep my personal items within reach when I sit in my easy chair." "I haven't changed the batteries in the smoke detectors in my home for quite a few years now."

"I don't have any nightlights in the house." "I haven't changed the batteries in the smoke detectors in my home for quite a few years now."

A home health nurse has instructed a client about safety measures during the use of an oxygen concentrator in the home. Which statement by the client indicates to the nurse that the client understands the directions? Select all that apply. "I need to follow the oxygen prescription exactly." "I can use my electric razor while I'm using oxygen." "I have to keep the oxygen concentrator out of direct sunlight." "I need to keep the oxygen concentrator as close to the wall as possible or put it in a corner." "I have to tell everyone that they can't smoke or have an open flame within 10 feet (3 meters) of the oxygen concentrator."

"I need to follow the oxygen prescription exactly." "I have to keep the oxygen concentrator out of direct sunlight." "I have to tell everyone that they can't smoke or have an open flame within 10 feet (3 meters) of the oxygen concentrator."

A home health nurse teaches a client about home modifications to reduce the risk of falls. Which statements by the client indicate a need for further teaching? Select all that apply. "I need to use night lights." "I need to remove my wall-to-wall carpeting." "I need to get handrails put up in the bathroom." "I need to use the staircase handrails when I go up the stairs." "I should walk barefoot as much as possible so that I'll know about any wet spots on the floor."

"I need to remove my wall-to-wall carpeting." "I should walk barefoot as much as possible so that I'll know about any wet spots on the floor."

A client with osteoporosis is at risk for falls. Which statement by the client indicates the need for instruction regarding measures to prevent falls? "I took the bathmat out of my tub." "I use a shower chair when I bathe." "I've placed nightlights in my hallway." "The railings on my stairs are sturdy and secure."

"I took the bathmat out of my tub."

A nurse has provided instructions to a mother regarding the use of safety seats in car travel for her newborn infant. Which statement by the mother indicates understanding of the instructions? "I'll put the baby's car seat in the front seat, facing forward and reclined a little." "I'll put the baby's car seat in the front seat, facing backward and reclined a little." "I'll put the baby's car seat in the middle back seat, facing forward and reclined a little." "I'll put the baby's car seat in the middle back seat, facing backward and reclined a little."

"I'll put the baby's car seat in the middle back seat, facing backward and reclined a little."

A teenage client returns to the gynecological (GYN) clinic for a follow-up visit after diagnosis and initial treatment of a sexually transmitted infection (STI). Which statement by the client indicates the need for further teaching? "I finished all the antibiotic, just like you said." "I know you won't tell my parents that I'm sick." "I always make sure my boyfriend uses a condom." "My boyfriend doesn't have to come in for treatment."

"My boyfriend doesn't have to come in for treatment."

A nurse leading an educational session about terrorism for members of the community is discussing anthrax. Which of the following pieces of information should the nurse provide to the group attending the session? Select all that apply. Anthrax is never fatal. No vaccine to prevent anthrax is available. Anthrax can be transmitted from person to person. A blood test is available for the detection of anthrax. One way that anthrax can be contracted is through the skin.

A blood test is available for the detection of anthrax. One way that anthrax can be contracted is through the skin.

A fever develops in a client who has been hospitalized for 2 months and is receiving parenteral nutrition by way of a central venous line, and central venous line-related sepsis is diagnosed. What does the nurse interpret the meaning of this infection? Select all that apply. A nosocomial infection An iatrogenic infection A result of bacterial colonization A community-acquired infection A healthcare-associated infection A hospital-acquired infection

A healthcare-associated infection A nosocomial infection A hospital-acquired infection

An emergency department (ED) nurse is triaging victims of an explosion at a nearby manufacturing plant. To which victims should the nurse assign the emergent (priority 1) designation? Select all that apply. A victim with a limb amputation A victim with burns of both arms A victim who is alert but complaining of loss of vision A victim who is dazed and staggering around the other victims A victim who has sustained minor bruising of an arm and the lower legs

A victim with a limb amputation A victim who is dazed and staggering around the other victims

A nurse responds to an external disaster that occurred in a large city when a building collapsed. Numerous victims require treatment. Which victim should the nurse attend to first? A victim who has died of multiple serious injuries A hysterical victim who has sustained a head injury An alert victim who has numerous bruises on the arms and legs A victim with a partial amputation of a leg who is bleeding profusely

A victim with a partial amputation of a leg who is bleeding profusely

A triage nurse in an emergency department (ED) is attending to the victims of a train crash. All victims are alert. Which of these clients does the nurse assign to the emergent category? Select all that apply. A victim with respiratory distress A victim with a fractured humerus A victim with partial amputation of the foot A victim with a forehead laceration that is not bleeding A victim with multiple nonbleeding bruises of the arms and legs

A victim with respiratory distress A victim with partial amputation of the foot

An older client in a long-term care facility is at risk for injury because of confusion. Which of the following devices would be the best choice to help prevent injury while the client is in bed?

Bed alarm

An older client is extremely anxious after admission, having never been hospitalized before. To help provide a safe environment and minimize the stress of hospitalization on the client, what does the nurse plan to do? Select all that apply. Keep visitors to a minimum Acknowledge the client's feelings Provide information about hospital routines Put the client in a room far from the nurses' station Keep the door open and the room lights on at all times Allow the client to have as many choices regarding his care as possible

Acknowledge the client's feelings Provide information about hospital routines Allow the client to have as many choices regarding his care as possible

According to the Federal Emergency Management Agency (FEMA) description of the phases of disaster management, what are the components of actions in the mitigation phase? Select all that apply. Actions taken to return to normal after the disaster Putting disaster-planning services into action Actions that can prevent the occurrence of a disaster Measures that can reduce a disaster's damaging effects Actions that plan for rescue, evacuation, and care of disaster victims Determining available resources for the care of infants, older clients, the disabled, and people with chronic health problems

Actions that can prevent the occurrence of a disaster Measures that can reduce a disaster's damaging effects Determining available resources for the care of infants, older clients, the disabled, and people with chronic health problems

A hurricane is forecast to make landfall in 48 hours, and the staff of the emergency department of an area hospital is advised to prepare for causalities. Which action should the nurse manager who receives the telephone call regarding this warning take first? Activate the agency disaster plan Supply the triage rooms with additional equipment Increase the number of nursing staff for the day on which the hurricane is expected Call the hospital maintenance department to secure the building against the storm

Activate the agency disaster plan

A nurse enters the laundry room to empty a bag of dirty linen and discovers a fire in a laundry basket. What action should the nurse take first? Confining the fire Extinguishing the fire Activating the fire alarm Running for the fire extinguisher

Activating the fire alarm

A nurse in a post-anesthesia care unit (PACU) receives a client from the operating room. For what finding should the PACU nurse assess the client first? Airway patency Active bowel sounds Adequate urine output Orientation to surroundings

Airway patency

A hospitalized client, experiencing confusion, is at risk of falling because she continually tries to climb out of bed. Which of these safety devices that the nurse might suggest is the least restrictive? Belt Wrist Elbow Ambularm

Alarm

An industrial nurse at a large factory provides information to the employees in the mailroom and shipping department about the signs of skin (cutaneous) anthrax. For which early sign of cutaneous anthrax does the nurse tell the employees to check their skin? An open ulcer An itchy bump A weeping blister A black skin area of skin

An itchy bump

A nurse is performing sterile wound irrigation for an assigned client. A nursing assistant enters the client's room and tells the nurse that a primary health care provider has telephoned and has asked to speak to the nurse. What is the appropriate action by the nurse? Asking the nursing assistant to take a message Covering the client and answering the telephone call Finishing the wound irrigation while the primary health care provider waits on the telephone Asking the nursing assistant to obtain a telephone number from the primary health care provider so that the nurse may return the call after the wound irrigation is complete

Asking the nursing assistant to obtain a telephone number from the primary health care provider so that the nurse may return the call after the wound irrigation is complete

A licensed practical nurse (LPN) tells the registered nurse (RN) that she administered acetaminophen to a client by way of the rectal route rather than the prescribed oral route because the client was extremely nauseated. What is the most appropriate action by the RN? Asks the LPN to complete and file an incident report Asks the LPN to check the client in 30 minutes to see whether the nausea has subsided Tells the LPN that she made a sound judgment in administering the medication by way of the rectal route Instructs the LPN to write "pr" (per rectum) on the medication record next to the time at which the medication was administered

Asks the LPN to complete and file an incident report

A home care nurse is visiting an older client who has been recovering from a mild brain attack (stroke) affecting her left side. The client lives alone but receives regular assistance from her daughter and son, who both live within 10 miles. Which of the following actions should the nurse take to assess the client's safety risk? Select all that apply. Assess the client's visual acuity Observe the client's gait and posture Evaluate the client's muscle strength Look for any hazards in the home environment Ask a family member to move in with the client until her recovery is complete Request that the client transfer to an assisted living environment for at least 1 month

Assess the client's visual acuity Observe the client's gait and posture Evaluate the client's muscle strength Look for any hazards in the home environment

A military nurse who is in charge of planning a vaccination clinic to administer the smallpox vaccine to military personnel is preparing a pamphlet that sets forth guidelines for care of the vaccination site. Which guideline should the nurse include in the pamphlet? Soak the scab that forms with warm water every day. Keep the vaccination site open to air as much as possible. Apply an antihistamine ointment to the scab to prevent itching. Avoid sharing towels or other items that have come in contact with the vaccination site.

Avoid sharing towels or other items that have come in contact with the vaccination site.

A sedated client is being transported to the radiology department on a stretcher. Which type of restraint should the nurse suggest applying to help ensure the client's safety? Belt Wrist Elbow Mitten

Belt

A nurse employed in a physician's office hears a client in the waiting room call out, "Help! Fire!" The nurse rushes to the waiting room and finds that the wastebasket is on fire. What should the nurse immediately do? Confine the fire Extinguish the fire Activate the fire alarm Remove the clients from the waiting room

Remove the clients from the waiting room

The mother of a 3-year-old calls a neighbor who is a nurse and reports that her child just drank some window cleaner that had been stored in a cabinet. What should the nurse instruct the mother to do immediately? Call a poison control center Administer an excessive amount of fluids to induce vomiting Call an ambulance to bring the child to the emergency department Leave a message on the primary health care provider's answering service about the incident

Call a poison control center

A community health nurse is providing an educational session on childhood poisoning at a local school. What does the nurse tell the group what the first action is when an accidental poisoning occurs? Induce vomiting Call an ambulance Call the poison control center Bring the child to the emergency department (ED)

Call the poison control center

A nurse manager of an emergency department (ED) arrives at work and is told that four registered nurses scheduled to work will not be reporting to work because they are ill. Every trauma room is busy, and emergency medical services (EMS) has just called to report that several victims involved in a 10-car wreck on the interstate will be brought to the ED. How does the nurse manager initially manage this situation? Telling EMS to take the victims to another hospital Closing the emergency department temporarily to incoming clients Calling the nursing supervisor to discuss activation of the disaster plan Demanding that the nurses from the night shift stay until all of the victims have been treated

Calling the nursing supervisor to discuss activation of the disaster plan

An adolescent client asks the nurse questions about the transmission of the Epstein-Barr virus (infectious mononucleosis). By which route should the nurse tell the client that the disease is transmitted? Fecal-oral Airborne particles Respiratory droplets Close intimate contact

Close intimate contact

A nurse in a long-term care facility recognizes the need to place wrist restraints on a client, but the client does not want the restraints applied. What would be the most appropriate action by the nurse? Contact the primary health care provider Apply the restraints anyway Medicate the client with a sedative, then apply the restraints Compromise with the client and use only one wrist restraint instead of two

Contact the primary health care provider

A nurse is discussing accident prevention with the family of an older client who is being discharged from the hospital after hip surgery. This client has a tendency to be forgetful. Which items in the home increase the client's risk for injury? Select all that apply. A nightlight in the bathroom Elevated toilet seat with armrests Cooking equipment such as a stove Smoke and carbon monoxide detectors Common household objects such as door mats A water heater thermostat adjusted to a low setting

Cooking equipment such as a stove Common household objects such as door mats

A physician writes a prescription for the application of a heating pad to a client's back. Which of the following actions should the nurse take when implementing this prescription? Select all that apply. Placing the heating pad under the client Adjusting the heating pad to the high setting Frequently assessing the client's skin for signs of burns Assessing the client's medical history and risk factors for burns Assessing the heating pad periodically for proper electrical function

Frequently assessing the client's skin for signs of burns Assessing the client's medical history and risk factors for burns Assessing the heating pad periodically for proper electrical function

A nurse educator is providing an in-service program to emergency department nurses about the signs/symptoms of inhalation anthrax. What does the nurse educator tell the nurses is an early indication of inhalation anthrax? Hemorrhage Signs/symptoms of shock Flulike signs/symptoms Respiratory distress

Flulike signs/symptoms

A registered nurse(RN)is watching as a new licensed practical nurse(LPN) suctions a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). Which of the following protective devices worn by the LPN would cause the RN to determine that the LPN was performing the procedure safely? Gloves and mask Gloves and gown Gloves, gown, and face shield Gown and protective eyewear

Gloves, gown, and face shield

A nurse is assigned to care for a client with an infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator that requires frequent suctioning. While gathering the needed supplies before entering the client's room, which necessary protective items does the nurse obtain? Select all that apply. Mask Gown Gloves Face shield Shoe protectors

Gown Gloves Face shield

A nurse manager tells the nursing staff that the agency's disaster preparedness plan will be distributed to all employees for review. What does the nurse manager say is a primary component of disaster readiness? Identify the location of healthcare supplies Identify the types of disasters that may occur Aid determination of how victims will be triaged Describe a formal plan of action for the coordination of a response

Describe a formal plan of action for the coordination of a response

A nurse is preparing to initiate a continuous tube feeding, using a tube-feeding pump. On bringing the pump to the bedside and preparing to plug the pump in, the nurse discovers that there is no available plug in the wall socket. What is the most appropriate action the nurse should do? Plug in the pump cord into an available plug above the sink Ask the primary health care provider to change the prescription to intermittent feedings Determine the need for the appliances now plugged into the needed wall socket Use a regular extension cord to allow the use of more than one electrical appliance

Determine the need for the appliances now plugged into the needed wall socket

A community health nurse working in a school setting is concerned because parents are not participating in health activities designed to promote child safety. What is the most appropriate initial action for the nurse to take? Implementing a child safety program Planning a focused child safety program Performing an analysis of health problems related to child safety Determining the appropriateness of the planned health activity

Determining the appropriateness of the planned health activity

A nurse preparing to perform a sterile dressing change notes that the covering of a package of sterile 4 × 4 gauze pads has a small tear. Which action should the nurse take? Discard the package Use the gauze pads, because the tear was small Examine the gauze pads and using them as long as they appear untouched Discard the gauze pad closest to the outside of the package and using the others

Discard the package

A home health nurse is visiting a client with tuberculosis (TB). Which action by the client tells the nurse that the client understands the necessary respiratory precautions to be taken at home? Staying secluded in the bedroom Wearing an oxygen mask at all times Keeping the house closed up to minimize the spread of disease Disposing of contaminated tissues in a container with a leak-proof bag

Disposing of contaminated tissues in a container with a leak-proof bag

A nurse is preparing a sterile field to change a client's sterile dressing. What are some sterile techniques the nurse must adhere to? Select all that apply. Do not turn your back to the sterile field at any time. A half-inch border of the sterile field is considered contaminated. Cuff the top of the disposable paper bag, and place it within reach of the work area. Maintain the sterile field and gloved hands above the level of the waist. Make sure to use sterile gloves when opening up sterile gauze packages to place on the sterile field.

Do not turn your back to the sterile field at any time. Maintain the sterile field and gloved hands above the level of the waist.

A community health nurse is asked to assist in developing a community disaster plan identified by Federal Emergency Management Agency (FEMA). The nurse knows that the preparedness phase of the plan includes what components? Select all that apply. Evacuation Planning for rescue Caring for disaster victims Training of disaster personnel Putting disaster planning services into action Actions to prevent the occurrence of a disaster or reduce the damaging effects

Evacuation Planning for rescue Caring for disaster victims Training of disaster personnel

A nurse is attending an in-service program on disaster preparedness. Which of the following events are described as examples of natural disasters? Select all that apply. Flood Drought Bus accident Terrorist attack Toxic waste spill Hurricane

Flood Drought Hurricane

Which of the following actions are in keeping with the principles of standard precautions? Select all that apply. Handwashing between client contacts Cleaning of blood spills with soap and warm water Discarding needles in puncture-resistant containers Handwashing before removal of a pair of soiled gloves Wearing a face shield as a part of the protective garb during a wound irrigation Wearing a gown and gloves when changing the linens on the bed of a client with a draining lesion of the leg

Handwashing between client contacts Discarding needles in puncture-resistant containers Wearing a face shield as a part of the protective garb during a wound irrigation Wearing a gown and gloves when changing the linens on the bed of a client with a draining lesion of the leg

A nurse is preparing a disaster preparedness checklist, identifying emergency plans and supplies that will be needed in the event of a disaster, for a community group. Which instructions should be included on the list? Select all that apply. Have a first aid kit available. Have a firearm or other weapon available. Plan a meeting place for family members. Obtain a 1-day supply of water (1 gallon per person). Have an adequate supply of prescription medications. Have a battery-operated radio and a flashlight and batteries available.

Have a first aid kit available. Plan a meeting place for family members. Have an adequate supply of prescription medications. Have a battery-operated radio and a flashlight and batteries available.

Which of the following statements reflect the principles of sterile technique? Select all that apply. The clients overbed table is wiped with chlorhexidine. If a package is not labeled as sterile, it should be considered unsterile. Sterile objects that come in contact with unsterile objects are to be considered contaminated. Any part of a sterile field that hangs below the top of the table is sterile as long as it is not touched. When a sterile field becomes wet, it remains sterile as long as the items on the field are not touched. Items in a sterile package must be used immediately once the package has been opened; otherwise they are considered contaminated.

If a package is not labeled as sterile, it should be considered unsterile. Sterile objects that come in contact with unsterile objects are to be considered contaminated. Items in a sterile package must be used immediately once the package has been opened; otherwise they are considered contaminated.

The nursing staff in an emergency department is reviewing and updating the disaster preparedness plan. The staff members, discussing ways to help prevent the transmission of smallpox, know that this infection is transmitted by which route? Select all that apply. Enteric Inhalation Direct contact Gastrointestinal Through open wounds Handling of contaminated materials

Inhalation Direct contact Handling of contaminated materials

A client undergoing chemotherapy is found to have an extremely low white blood cell count, and neutropenic precautions, including a low-bacteria diet, are immediately instituted. Which of these food items will the client be allowed to consume? Select all that apply. Fresh apple Raw celery Italian bread Tossed salad Baked chicken Well-cooked cheeseburger

Italian bread Baked chicken Well-cooked cheeseburger

Which of these interventions does a nurse manager, reviewing infection control interventions with the nursing staff, tell the staff will reduce reservoirs of infection? Select all that apply. Keeping bedside table surfaces clean and dry Placing tissues and soiled dressings in paper bags Changing dressings that become wet or soiled Placing capped needles and syringes in puncture-resistant containers Using soap and water to remove drainage, dried secretions, or excess perspiration from a client's skin Emptying urinary drainage systems (Foley catheter drainage) on each shift unless prescribed otherwise by a physician

Keeping bedside table surfaces clean and dry Changing dressings that become wet or soiled Using soap and water to remove drainage, dried secretions, or excess perspiration from a client's skin Emptying urinary drainage systems (Foley catheter drainage) on each shift unless prescribed otherwise by a physician

What is an example of the nurse using surgical asepsis? Applying a gown and gloves Handling hazardous and infectious materials Reducing the number of organisms and preventing their spread Maintaining objects and areas free from pathogenic microorganisms

Maintaining objects and areas free from pathogenic microorganisms

A nurse caring for a client with leukemia who is undergoing chemotherapy reviews the latest laboratory results and notes that the neutrophil count is below 500 cells/mm3 (0.5 x 109/L). Which of the following interventions does the nurse implement on the basis of this finding? Select all that apply. Providing a soft toothbrush for oral care Monitoring the client's oral temperature Maintaining sterile occlusion of intravenous (IV) catheters Requiring the client to use an electric shaver rather than a razor Performing meticulous skin decontamination before venipuncture Avoiding overinflation of the blood pressure cuff and rotating the cuff among several sites when measuring the blood pressure

Monitoring the client's oral temperature Maintaining sterile occlusion of intravenous (IV) catheters Performing meticulous skin decontamination before venipuncture

A nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the IV tubing port to the solution bag, the tubing drops, hitting the top of the medication cart. Which action should the nurse take to maintain asepsis? Obtain new IV tubing Obtain a new IV solution bag Scrub the tubing port with an alcohol swab Wipe the tubing port with povidone-iodine solution

Obtain new IV tubing

The nurse plans to wear this protective mask (see figure) when caring for clients with certain disorders. What are these disorders? Select all that apply. Scabies Hepatitis A Tuberculosis Pharyngeal diphtheria Streptococcal pharyngitis Meningococcal pneumonia

Pharyngeal diphtheria Streptococcal pharyngitis Meningococcal pneumonia

A nurse caring for a client who is under airborne precautions notes that the client is scheduled for a nuclear scan. Which action on the part of the nurse is appropriate? Planning to have the nuclear scan performed at the bedside Asking the technicians in the nuclear scan department to wear masks Placing a surgical mask on the client for transport and for contact with other individuals Calling the nuclear medicine department and telling the technician that the test will have to be delayed until airborne precautions have been discontinued

Placing a surgical mask on the client for transport and for contact with other individuals

A nurse, preparing a sterile field on which to perform a dressing change, places the sterile drape on the overbed table. Which of these actions on the part of the nurse indicate correct understanding of the principles of aseptic technique? Select all that apply. Holding the pair of sterile forceps below waist level area Positioning the sterile field so that it remains in full view Reaching across the sterile field to pick up a sterile gauze Leaving the room to obtain a bottle of sterile normal saline solution Picking up a pair of sterile scissors from the sterile field with a sterile gloved hand Pouring sterile wound cleansing solution into a sterile cup before donning sterile gloves

Positioning the sterile field so that it remains in full view Picking up a pair of sterile scissors from the sterile field with a sterile gloved hand Pouring sterile wound cleansing solution into a sterile cup before donning sterile gloves

A nurse is reading an article about the role of the American Red Cross (ARC) in a disaster. Which of the following responsibilities does the article ascribe to the ARC? Select all that apply. Declaring a disaster Providing disaster relief Activating disaster medical assistant teams Developing a federal disaster response plan Educating the public about ways to prepare for disasters

Providing disaster relief Identifying and training personnel for disaster response Educating the public about ways to prepare for disasters

The safety department is providing a yearly educational session on fire safety and the use of fire extinguishers. A nurse is asked to demonstrate the use of a fire extinguisher after the session. What does the nurse do first when demonstrating appropriate use of the fire extinguisher? Aiming at the base of the fire Pulling the pin on the fire extinguisher Squeezing the handle of the extinguisher Sweeping from the top to the bottom of the fire with the extinguisher

Pulling the pin on the fire extinguisher

A home health nurse is performing an assessment of a client's skin. The nurse, noting multiple threadlike lines, both straight and wavy, beneath the skin, recognizes the presence of scabies. Which of the following precautions should the nurse institute before completing the assessment of the client? Putting on a pair of gloves Donning a mask and gloves Putting on a gown and gloves Avoiding sitting on the client's furniture

Putting on a gown and gloves

A nurse is admitting a postoperative client from the post-anesthesia care unit (PACU)to the surgical nursing unit. Which of the following measures should the nurse take for the safety of the client? Asking the client to slide from the stretcher to the bed Quickly moving the client from the stretcher to the bed Putting the side rails up after moving the client from the stretcher Uncovering the client before making the transfer from the stretcher to the bed

Putting the side rails up after moving the client from the stretcher

The nurse administers a dose of ramipril 2.5 mg to a client at 9 am. While documenting administration of the medication, the nurse discovers that 1.25 mg, not 2.5 mg, was the prescribed dose. The nurse assesses the client, completes an incident report, and notifies the primary health care provider and nursing supervisor of the error. What statement does the nurse add to the client's record? An incident report was completed and filed. Ramipril 2.5 mg was administered at 9 am. Twice the amount of the prescribed ramipril was administered at 9 am. Client's blood pressure was 128/82 mm Hg after the administration of the incorrect dose of ramipril.

Ramipril 2.5 mg was administered at 9 am.

A client with paraplegia has spasticity of the leg muscles. Which nursing interventions should be included in the plan of care for this client? Select all that apply. The use of restraints to immobilize the limbs Range-of-motion exercises of the affected limbs An as-needed prescription for a muscle relaxant Removal of potentially harmful objects near the client The use of padding against the client's legs when the client is sitting in a wheelchair

Range-of-motion exercises of the affected limbs An as-needed prescription for a muscle relaxant Removal of potentially harmful objects near the client The use of padding against the client's legs when the client is sitting in a wheelchair

A nurse caring for a 9-month-old who has undergone repair of a cleft palate applies elbow restraints to the child. The mother visits her child and asks the nurse to remove the restraints. According to the guidelines for the use of restraints, what should the nurse do in response to the mother's request? Remove both restraints Remove a restraint from one extremity Tell the mother that the restraints may not be removed Loosen the restraints after telling the mother that they may not be removed

Remove a restraint from one extremity

Which actions should the nurse take in the event of an accidental poisoning? Select all that apply. Saving vomitus for laboratory analysis Placing the client in the supine position Determining the type and amount of substance ingested Removing any visible materials from the nose and mouth Inducing vomiting if a household cleaner has been ingested Assessing the client's airway patency, breathing, and circulation

Saving vomitus for laboratory analysis Determining the type and amount of substance ingested Removing any visible materials from the nose and mouth Assessing the client's airway patency, breathing, and circulation

Which of the following points should the nurse include when documenting information about a client who is wearing wrist restraints? Select all that apply. The client's temperature The client's 24-hour urine output Skin integrity of the restrained body part The procedure used in applying the restraint The date and time of application of the restraint Circulatory and neurovascular status of the restrained extremities

Skin integrity of the restrained body part The procedure used in applying the restraint The date and time of application of the restraint Circulatory and neurovascular status of the restrained extremities

A community health nurse is providing information to local residents about the transmission of anthrax. Through which body systems does the nurse tell the residents that anthrax can be contracted? Select all that apply. Immune Urinary Lymphatic Respiratory (Lungs) Gastrointestinal Integumentary System (Skin)

Skin, lungs, GI

A staff nurse caring for a client with a head injury notes that the client is restless and pulling at the intravenous (IV) line. The client's primary health care provider does not want to prescribe sedation, and the family has requested that the client not be restrained. Which action by the nurse is best? Asking a family member to sit with the client Asking a nursing assistant to monitor the client Staying with the client and consulting with the nurse manager about the situation Telling the family that the application of wrist restraints is critical in preventing injury to the client

Staying with the client and consulting with the nurse manager about the situation

A client with an infection is receiving antibiotics by way of intramuscular (IM) injection. The client is also receiving subcutaneous (SC) injections of heparin. Which precautions does the nurse understand are most appropriate to help ensure the safety of this client? Select all that apply. Switching injection sites Doubling the dose of anticoagulant Applying a pressure bandage to the site after each IM injection Applying prolonged pressure to the sites of the IM and SC injections Decreasing the sizes of the needles used for the IM and SC injections

Switching injection sites Applying prolonged pressure to the sites of the IM and SC injections

A nurse, charting the administration of medications to an assigned client at 9 pm, notes that atenolol was prescribed to be administered at 9 am instead of 9 pm. The nurse checks the client's vital signs, completes an incident report, and calls the primary health care provider to report the error. The primary health care provider tells the nurse that an incident report is not needed but instructs her to monitor the client during the night for hypotension. What action should the nurse take? Notify the nursing supervisor Tear up and discard the incident report Tell the primary health care provider that the error warrants the completion of an incident report Tell the nursing supervisor that the primary health care provider did not want an incident report completed and filed

Tell the primary health care provider that the error warrants the completion of an incident report

A nurse is assisting with disaster relief after a tornado. The nurse's goal with the overall community is to prevent as much injury and death resulting from the uncontrollable event as possible. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are all examples of which level of prevention? Initial Primary Tertiary Secondary

Tertiary

A nurse provides instruction to a new nursing assistant regarding the application of a restraint to a client. The nurse watches as the nursing assistant applies the restraint. What observation tells the nurse that the nursing assistant is using correct procedure? The assistant applies a tie knot in the restraint strap. The assistant attaches the restraint straps securely to the side rails. The assistant applies the restraint so that the strap does not tighten when force is applied against it. The assistant secures the restraint in such a way that it is impossible to slip a finger between the restraint and the client's skin.

The assistant applies the restraint so that the strap does not tighten when force is applied against it.

A registered nurse is instructing a group of nursing assistants in the principles of body mechanics. Which of these observations tell the nurse that a student is using the principles appropriately? Select all that apply. The assistant leans forward when turning a client in bed. The assistant positions a box that is to be lifted between his knees. The assistant turns his back to change position while moving a client. The assistant keeps the object to be moved as close to his body as possible. The assistant helps a client requiring total care into a chair without additional assistance.

The assistant positions a box that is to be lifted between his knees. The assistant keeps the object to be moved as close to his body as possible.

A home health nurse has been called to the home of an older postoperative cardiovascular client by the client's son. The son tells the nurse, "We're using a hospital bed here at home, but my mother has fallen out of bed three times." Which observation by the nurse reflects an increased risk of this client's falling out of bed? The client's bed is in a low position. The client is oriented to person, place, and time. The caregiver uses the overbed table for feedings. The caregiver leaves both side rails down while the client is in bed.

The caregiver leaves both side rails down while the client is in bed.

Wrist restraints have been prescribed for a client who is constantly pulling at his gastrostomy tube. Which findings does the nurse, developing a care plan, recognize as unexpected outcomes related to the use of restraints? Select all that apply. The client becomes agitated. The skin under the restraint is red. The client's left hand is pale and cold. The client verbalizes the reason for the restraints. The client is unable to reach the gastrostomy tube with his hands. The client slips his hand from its restraint and pulls at his gastrostomy tube.

The client becomes agitated. The skin under the restraint is red. The client's left hand is pale and cold. The client slips his hand from its restraint and pulls at his gastrostomy tube.

A client with a new diagnosis of tuberculosis (TB) is being admitted to the hospital. During the collection of data from the client, which of the following considerations is most important? The religious affiliation or church of preference The names of close friends and family members What medications have been prescribed and what the client knows about his or her side effects The name of the person from whom the client contracted TB, so that the person may be reported for follow-up care

The names of close friends and family members

During a laboratory training session, the nurse is watching as a nursing assistant repositions a client. Which observation tells the nurse that further training is necessary? The nursing assistant positions himself/herself close to the client. The nursing assistant keeps his/her neck, back, pelvis, and feet aligned. The nursing assistant encourages the client to assist as much as possible. The nursing assistant keeps his/her knees straight and his/her feet close together.

The nursing assistant keeps his/her knees straight and his/her feet close together.

A nursing instructor is observing a nursing student who is practicing the use of standard precautions in the nursing laboratory. Which of the following observations by the instructor indicates a need for further teaching? The nursing student changes gloves between tasks and procedures. The nursing student washes hands before making contact with the client. The nursing student wears a gown to change the bed of an incontinent client. The nursing student washes her hands before glove removal after emptying a Foley bag.

The nursing student washes her hands before glove removal after emptying a Foley bag.

At the beginning of the 7 am-3 pm shift, the nurse checks her assigned clients and notes that a client with diabetes mellitus has an intravenous (IV) bag of 5% dextrose in water hanging and infusing instead of the prescribed 0.9% normal saline. The nurse verifies the prescription and changes the IV solution to the correct one. The nurse assesses the client noting that the blood glucose level at 7:15 am was 149 mg/dL (8.3 mmol/L), notifies the primary health care provider, and completes an incident report. Which information about the event is appropriate for inclusion on the incident report? Select all that apply. The primary health care provider was contacted. The blood glucose level at 7:15 am was 149 mg/dL (8.3 mmol/L). An IV solution of 5% dextrose in water was infusing at 7 am. A solution of 5% dextrose in water was infusing instead of the prescribed 0.9% normal saline solution. A 5% dextrose in water soluti

The primary health care provider was contacted. The blood glucose level at 7:15 am was 149 mg/dL (8.3 mmol/L). An IV solution of 5% dextrose in water was infusing at 7 am.

After discussing the use of restraints with a client and family, the primary health care provider has written a prescription for wrist restraints to be applied to a client. The nurse instructs the nursing assistant to apply the restraints. Which of the following observations by the nurse indicates that the nursing assistant is using the restraints safely and correctly? Select all that apply. The restraints are applied tightly. The restraints are being released every 2 hours. A safety knot has been used to secure the restraints. The restraints have been tied to the side rails of the bed. The call light has been placed within reach of the client.

The restraints are being released every 2 hours. A safety knot has been used to secure the restraints. The call light has been placed within reach of the client.

A nurse educator is providing in-service sessions to the nursing staff regarding employee safety and the prevention of occupationally acquired HIV infection. Which of the following precautions does the nurse instruct the nursing staff to take as a means of preventing accidental needlesticks? Select all that apply. The use of latex gloves The use of shielded needles The use of recessed needles The use of needleless devices Disposal of needles in special puncture-resistant containers

The use of shielded needles The use of recessed needles The use of needleless devices Disposal of needles in special puncture-resistant containers

In which of the following situations would the nurse use this type of restraint (see figure)? Select all that apply. To secure the shoulders and the waist To immobilize a client's arm and shoulders To prevent the client from getting out of bed To prevent dislodgment of an intravenous line To prevent the client from turning from side to side To prevent the use of the hands while allowing free arm movement

To prevent dislodgment of an intravenous line To prevent the use of the hands while allowing free arm movement

Contact precautions are initiated for a client with methicillin-resistant Staphylococcus aureus (MRSA) infection. What does the nurse, providing instructions to a nursing assistant about caring for the client, tell the assistant? To transfer the client to a semiprivate room That gloves only are needed to care for the client To wear gloves and a gown when changing the client's bed linen. To wear a gown when caring for the client and remove the gown immediately after leaving the client's room

To wear gloves and a gown when changing the client's bed linen.

A nurse is reading the history and physical examination findings of an older client who has just been admitted to the hospital. Which findings documented in the history indicate an increased risk for accidents? Select all that apply. Increased lens accommodation Transmission of hot impulses is delayed. The client's peripheral vision is decreased. The client complains of frequent nocturia. High-frequency hearing tones are perceptible. Voluntary and autonomic reflexes are slowed.

Transmission of hot impulses is delayed. The client's peripheral vision is decreased. The client complains of frequent nocturia. Voluntary and autonomic reflexes are slowed.

A nurse is questioning a client about hazards in the home environment. Which of the following items in the home is an indication that the client requires instruction about safety? Select all that apply. Untacked rugs on the stairs Small rugs in the living room Carpet on stairs secured with tacks Clothes hamper at the end of the hallway Cereal boxes, canned foods, and infrequently used cooking utensils stored on top of the refrigerator

Untacked rugs on the stairs Small rugs in the living room Cereal boxes, canned foods, and infrequently used cooking utensils stored on top of the refrigerator

A nurse is preparing to clean up a blood spill on the client's bedside table that occurred when a blood tube containing a specimen from the client broke. What steps should the nurse take to clean up the blood spill? Select all that apply. Using tongs to collect any broken glass Wearing gloves for the cleanup procedure Placing the pieces of broken glass in a plastic bag Blotting up the spill with a face cloth or cloth towel Disinfecting the area of the blood spill with a dilute bleach solution

Using tongs to collect any broken glass Wearing gloves for the cleanup procedure Disinfecting the area of the blood spill with a dilute bleach solution

A nurse employed on a medical care unit is administering medications. She tells a client that she is going to administer his furosemide through his intravenous (IV) line. The client tells the nurse that he takes this medication orally at home every day and is concerned that it is being administered by way of a different route. The nurse should take which most appropriate action? Verifying the primary health care provider's prescription Sitting and talking to the client to alleviate his concern Explaining to the client that the oral route will not permit the medication to exert an adequate effect Letting the client know that most medications are administered by way of the IV route when a client is hospitalized

Verifying the primary health care provider's prescription

A nurse giving a client a bed bath drops the towel on the floor. What should the nurse do? Use a bath blanket as a towel Borrow a towel from the client's roommate Wash his/her hands, pick up the towel, and shake the towel out Wash his/her hands and go to the linen room to obtain another towel

Wash his/her hands and go to the linen room to obtain another towel

Which of the following safety guidelines should the nurse include in the plan of care for a client with an internal radiation implant? Select all that apply. Wear a lead shield when in the client's room. Limit visits from family to 60 minutes per day. Wear a dosimeter film badge when in the client's room. Allow children to visit the client as long as they are at least 12 years old. Keep all bed linens and dressings in the client's room until the implant is removed.

Wear a lead shield when in the client's room. Wear a dosimeter film badge when in the client's room. Keep all bed linens and dressings in the client's room until the implant is removed.

A nurse receives a telephone call from the admissions office and is told that a client scheduled for an internal radiation implant will be admitted to the nursing unit. Which of the following precautions does the nurse include in the client's plan of care? Wearing gloves when emptying the client's bedpan Allowing the client to ambulate in the hall only once a day Placing the client in a semiprivate room at the end of a hallway Placing used linen in double bags and sending a bag to the laundry room every evening

Wearing gloves when emptying the client's bedpan

A nurse is preparing a chemotherapy infusion to be administered to a client with a diagnosis of Hodgkin's disease. Which precaution should the nurse take while working with this intravenous (IV) infusion? Wearing gloves and a mask Wearing gloves and a gown Wearing gloves, a mask, and eye protection Wearing gloves, a mask, and a head covering

Wearing gloves, a mask, and eye protection

Which event would require a nurse to complete and file an incident report? A client has a seizure. The nurse determines that a client would benefit from the use of a walker to ambulate. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor's blood pressure and takes the visitor to the emergency department for treatment.

When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor's blood pressure and takes the visitor to the emergency department for treatment.

A nurse performs an evaluation to determine whether a client's home is electrically safe. Which finding indicates the need for further investigation and intervention? Wiring for the television runs under the carpet. Electrical cords are free of frayed and damaged wires. Electrical kitchen appliances are located away from the sink. A safety-type extension cord is secured to the floor with electrical tape.

Wiring for the television runs under the carpet.

A home care nurse is instructing a client in the use of ice packs to treat an eye injury. What does the nurse instruct the client to do? Place the ice pack directly on the eye Avoid the use of commercially prepared ice bags Keep the ice pack on the eye continuously for 24 hours Wrap a plastic bag filled with ice in a pillowcase and place it on the eye

Wrap a plastic bag filled with ice in a pillowcase and place it on the eye

A nurse is providing instructions to a nursing assistant who will be caring for a client in hand restraints. How often does the nurse instruct the nursing assistant to release the restraints to permit muscle exercises? Every 2 hours Every 3 hours Every 4 hours Every 30 minutes

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