module 6

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.

pharyngeal diphtheria streptococcal pharyngitits 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?

placing a hepa 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 actions on the part of the nurse indicate correct understanding of the principles of aseptic technique? Select all that apply.

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

Which actions are means of maintaining medical asepsis to reduce and prevent the spread of microorganisms? Select all that apply.

practicing hand hygiene routinely cleaning the hospital environment wearing clean gloves to prevent direct contact with blood or body fluids

A community health nurse is asked to assist in developing a community disaster plan. The nurse determines that this responsibility is a component of which disaster management phase identified by the Federal Emergency Management Agency (FEMA)?

preparedness

A nurse is questioning a client about hazards in the home environment. Which items in the home are an indication that the client requires instruction about safety? Select all that apply.

untacked rugs on the stairs small rugs in the living room cereal boxes, canned foods, and infrequently used cooking untensils stored on top of the refrigerator

A home care nurse is instructing a client in the use of ice packs to treat an eye injury. The nurse instructs the client to take which action?

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

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 glooves for the cleanup procedure disinfecting the area of the blood spill with a dilute bleach solution

A nurse giving a client a bed bath drops the towel on the floor. The nurse should take which action?

washin her hand and go to the linen room to obtain another towel

Which 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 clients room wear a dosimeter film badge when in the client's room keep all bed linens and dressings in the clients room until the implant is removed

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

D

Which event would require a nurse to complete and file an incident report?

When a visitor suddenly becomes weak and dizzy, the nurse checks the visitors bp and takes the visitor to the emergency department for treatment

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?

my boyfriend doesn't have to come in for treatment

Contact precautions are initiated for a client with methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse, providing instructions to a nursing assistant about caring for the client, tells the assistant to take which action?

to wear gloves and a gown when changing the clients bed linen

A nurse is attending an inservice program on disaster preparedness. Which event is described as an example of a natural disaster?

drought

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?

activating the fire alarm

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?

obtaining new iv tubing

Wrist restraints have been prescribed for a client who is constantly pulling at his gastrostomy tube. Which findings does the nurse, following a care plan, recognize as unexpected outcomes related to the use of restraints? Select all that apply.

the client is agitated the skin under the restraint is red the clients left hand is pale and cold the client slips his hand from its restraint and pulls at his gastrostomy tube

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.

the clients range of motion is limited transmission of heat impulses is delayed the client's peripheral vision is decreased the client complains of frequent nocturia voluntary and autonomic reflexes are slowed

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?

discarding the package

Which points should the nurse include when documenting information about a client who is wearing wrist restraints? Select all that apply.

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 home health nurse has instructed a client about safety measures during the use of an oxygen concentrator in the home. Which statements by the client indicate to the nurse that the client has understood the directions? Select all that apply.

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 smoker or have an open flame within 10 feet of the oxygen concentrator

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.

acknowledge the clients feelings provide info about hospital routines allow the client to have as many choices regarding his care as possible

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 casualties. Which action should the nurse who receives the telephone call regarding this warning take first?

activating the agency disaster plan

A nurse in a postanesthesia care unit (PACU) receives a client from the operating room. For what finding should the PACU nurse assess the client first?

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?

ambularm

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 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 health care provider has telephoned and has asked to speak to the nurse. What is the appropriate action by the nurse?

asking the nursing assisrant to obtain a telephone number from the 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 (Tylenol) to a client by way of the rectal route rather than the prescribed oral route because the client was extremely nauseated. The RN most appropriately takes which action?

asks the lpn to complete and file an incident report

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?

antibiotic therapy is usually prescribed and will cure the infection

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 precaution does the nurse understand is most appropriate to help ensure the safety of this client?

applying prolonged pressure to the sites of the IM and SC sites

A health care provider writes a prescription for the application of a heating pad to a client's back. Which actions should the nurse take when implementing this prescription? Select all that apply.

frequently monitoring the client's skin for signs of burns Reviewing the client's medical history and risk factors for burns examining the heating pad periodically for proper electrical function

A nurse is watching as a newly hired nurse suctions a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). Which protective devices worn by the newly hired nurse would cause the nurse to determine that the new employee was performing the procedure safely?

gloves, gown, and face shield

The emergency department nurse who is on duty is informed by the charge nurse that an airplane crash has occurred and numerous casualties will be arriving at the ED. What should the initial response by the nurse be?

has the disaster plan been activated

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 actions should the nurse take to determine the client's safety risk? Select all that apply.

assessing the clients visual acuity observing the clients gait and posture evaluating the clients muscle strength looking 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?

avoid sharing towels or other items that have come inn 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

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. The nurse should instruct the mother to immediately take which action?

call a poison control center

A community health nurse is providing an educational session on childhood poisoning at a local school. The nurse tells the group that when an accidental poisoning occurs the first action is to take which action?

call the poison control center

A nurse, charting the administration of medications to an assigned client at 9 p.m., notes that atenolol (Tenormin) was prescribed to be administered at 9 a.m. instead of 9 p.m. The nurse checks the client's vital signs, completes an incident report, and calls the health care provider to report the error. The 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?

telling the health care provdier that the error warrants the completion of an incident report

A nurse is discussing accident prevention with the family of an older client who is being discharged from the hospital after hip surgery. Which items in the home increase the client's risk for injury? Select all that apply.

cooking equipment such as a stove common household objects such as doormats

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.

italian bread baked chicken well cooked cheeseburger

A nurse leading an educational session about terrorism for members of the community is discussing anthrax. Which pieces of information should the nurse provide to the group attending the session? Select all that apply.

a blood test is available for the detection of anthrax one way the anthrax can be contracted is though 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. The nurse interprets this finding as meaning that this is which type of infection?

a health care associated infection

A home care nurse visits a client during the winter, who lives in a small apartment, to perform a dressing change . During the lengthy procedure, 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 can be used as long as it's placed at least 3 feet from anything that may ignite

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 who is alert but complaining of loss of vision 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 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 partial amputation of the foot

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. The nurse demonstrates appropriate use of the fire extinguisher by first taking which action?

pulling the pin on the fire extingusher

A home health nurse is assisting with data collection of a client's skin. The nurse, noting multiple threadlike lines, both straight and wavy, beneath the skin, recognizes the presence of scabies. Which precautions should the nurse institute before completing the assessment of the client?

putting on a gown ad gloves

A nurse prepares to teach a client with chronic vertigo about safety measures to help prevent exacerbation of symptoms and injury. Which instructions should the nurse provide to the client? Select all that apply.

change position slowly remove clutter from your home

A nurse educator is providing inservice sessions to the nursing staff regarding employee safety and the prevention of occupationally acquired HIV infection. Which precautions does the nurse instruct the nursing staff to take as a means of preventing accidental needlesticks? Select all that apply.

the use of shielded needles the use of recessed needles the use of needless devices disposal of needles in special puncture restistant containers

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 precaution does the nurse include in the client's plan of care?

wearing gloves when emptying the clients bedpan

A nurse is removing a partially empty chemotherapy infusion bag that was used to administer to a client with a diagnosis of Hodgkin disease. Which precaution should the nurse take while working with this intravenous (IV) infusion?

wearing gloves, a mask and eye protection

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 tv runs under the carpet

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 remove my wall to wall carpeting i should walk barefoot as much as possible so that i'll know about ny 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

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?

ill put the baby's car seat in the middle back seat, facing backward and reclined a little

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?

inhalation

The licensed practical nurse (LPN), who is the unit charge nurse of a long-term care facility, arrives at work to find the entire facility has about an inch of standing water from a leak in the laundry room. Some residents have minor lacerations from slipping in the water. In addition, several nursing assistants and another staff LPN have called in due to illnesses. Several new residents are scheduled to be transferred to the long-term care facility from the hospital today. The nurse should initially manage the situation by taking which action?

calling the nursing supervisor to discuss activation of the disaster plan T

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?

close intimate contact

A nurse recognizes the need to place wrist restraints on a client, but the client does not want the restraints applied. Which is the appropriate nursing action?

contact the health care provider

A licensed practical charge nurse in a long-term care facility tells the nursing staff that the agency's disaster preparedness plan will be distributed to all employees for review. The nurse states that the plan is an important component of disaster readiness because it primarily has which purpose?

describes 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 in the pump, the nurse discovers that there is no available plug in the wall socket. What should the nurse do?

determine the need for 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. In this situation, which is the most appropriate initial action?

determining the appropriateness of the planned health care activity

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 infection control precautions to be taken at home?

disposing of contaiminated tissues in a container with a leak proof bag

A nurse is providing instructions to a nursing student who will be caring for a client in hand restraints. The nurse instructs the nursing student to release the restraints to permit muscle exercise how frequently?

every 2 hours

A nurse educator is providing an inservice program to emergency department nurses about the signs of inhalation anthrax. The nurse educator tells the nurses that which is an early indication of inhalation anthrax?

flulike symptoms

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

gown gloves face shield

The nurse is conducting inservice education for newly hired nursing assistants covering the topic of standard precautions. The nurse should explain that which actions are in keeping with the principles of standard precautions? Select all that apply.

handwashing between client contacts discarding needles in puncture resistant containers wearing a face shield as a part of the protective gard during a wound irrigation wearing a gown and gloves when changing 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 ad 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

A nurse who is assisting a client in preparing for discharge is asking questions to determine whether there are any environmental hazards in the home. Which statements, if made by the client, would prompt the nurse to investigate further? Select all that apply.

i dont have any nightlights in the house i haven't changed the batteries in the smoke detectors in my homes for quite a few years now

Which interventions does a nurse, reviewing infection control interventions with the nursing staff, tell the staff will reduce reservoirs of infection? Select all that apply.

keeping bedsider table surfaces clean and dry changing dressings that become wet or solied using soap and water to remove drainage dried secretions or excess persperations from a clients skin emtpying urinary drainage system (foley catheter drainage) on each shift unless prescribed otherwise by a health care provider

According to the Federal Emergency Management Agency (FEMA) description of the phases of disaster management, in which phase are the available resources for the care of infants, older clients, the disabled, and people with chronic health problems addressed?

mitigation

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. Which interventions does the nurse implement on the basis of this finding? Select all that apply

monitoring the clients oral temp maintaing sterile occlusion of IV catheters performing meticulous skin decontamination before veinpuncture

A nurse is reading an article about the role of the American Red Cross (ARC) in a disaster. Which responsibility does the article ascribe to the ARC?

providing disaster relief

A nurse is admitting a postoperative client from the postanesthesia care unit to the surgical nursing unit. Which measure should the nurse take for the safety of the client?

putting the siderails up after moving the client from the stretcher

The nurse administers a dose of ramipril 2.5 mg to a client at 9 a.m. 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 health care provider and nursing supervisor of the error. What statement does the nurse add to the client's record?

rampril 2.5 mg was administer at 9 am

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 a restraint from one extremity

A nurse employed in a health care provider'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. The nurse immediately takes which action?

removes the clients from the waiting room

A client with paraplegia has spasticity of the leg muscles. Which interventions does the nurse expect to be included in the plan of care for this client? Select all that apply.

rom exercises of the affected limbs PRN prescriptions for a muscle relaxant removal of potentially harmful objects near the client the use oof padding against the clients legs when the client is sitting in a wheelchair

Which actions should the nurse take in the event of an accidental poisoning? Select all that apply.

saving vomitus for labratory analysis determining the type and amount of substance ingested removing any visible material from the nose and mouth assessing the client airway patency, breathing, and circulation

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.

skin lungs gastrointestinal

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 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 appropriate?

staying with a client ad consulting with the nurse manager about the situation

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?

tertiary

A nurse is instructing a group of nursing assistants in the principles of body mechanics. Which observations tell the nurse that a nursing assistant is using the principles appropriately? Select all that apply.

the assistant positions a box that is too 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 caregiver leaves both siderails down while the client is in bed

The nurse has conducted a review of sterile technique for colleagues in the operating room. Which statements by the team members reflect understanding of the principles of sterile technique? Select all that apply.

the edge of sterile field and a border 1 inch inward is unsterile 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

A nurse provides instruction to a new nurse employee regarding the application of a restraint to a client. The nurse watches as the nurse employee applies the restraint. What observation tells the nurse that the nurse employee is using correct procedure?

the employee applies the restraints so that the strap does not tighten when force is applied against it

At the beginning of the 7 a.m. to 3 p.m. 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 a.m. was 149 mg/dL, notifies the 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 health care provider was contacted the blood glucose level at 7:15 was 149 mg/dL An iv solution of 5% dextrose in water was infusing at 7 am

A client with a new diagnosis of tuberculosis (TB) is being admitted to the hospital. During the collection of data from the client, which consideration is especially important?

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 keeps his knees straight and his feet close together

A nursing instructor is observing a nursing student who is practicing the use of standard precautions in the nursing laboratory. Which observation by the instructor indicates a need for further teaching?

the nursing student washes her hands before glove removal after emptying a foley bag

After discussing the use of restraints with a client and family, a health care provider has written a prescription for wrist restraints to be applied to a client. The nurse instructs the nursing student to apply the restraints. Which observations by the nurse indicates that the nursing student is using the restraints safely and correctly? Select all that apply.

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