Nclex: Safety
The client is observed falling out of bed when reaching for something on the overbed table. The client then states: "Don't just stand there. I feel fine - help me up." What is the correct order of actions the nurse should take? 1. assist the client back to bed, with help from other staff 2. obtain a complete set of vitals 3. call the HCP 4. complete an incident report
1. obtain a complete set of vitals 2. assist the client back to bed, with help from other staff 3. call the HCP 4. Complete an incident report The first step is always to assess the client for any obvious injuries and to obtain a complete set of vital signs (especially blood pressure) and neurologic assessments. If the client does not appear to be injured, staff members can assist the client back into bed. The nurse should then call the health care provider to report the incident. Finally, the nurse should complete the incident report. Of course, personal items should be placed close to the client so that they can reach them.
A parent calls the hospital hotline and is connected to the triage nurse. The caller states: "I found my child with odd stuff coming from the mouth and an unmarked bottle nearby." Which of these comments would provide the best information to help the nurse to determine if the child has swallowed a corrosive substance? A. "Ask the child if their mouth is burning or throat pain is present." B. "Has the child had vomiting, diarrhea or stomach cramps?" C. "Take the child's pulse at the wrist and see if the child has trouble breathing lying flat." D. "What color are the child's lips and nails and has the child voided today?"
A. "Ask the child if their mouth is burning or throat pain is present." Local irritation of tissues indicates a corrosive poisoning. The other comments may be helpful in determining the child's overall condition. However, the question concerns evaluation for ingestion of a caustic substance.
The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the discharge list in order to make room for a new admission? A. A middle-aged client with a seven-year history of being ventilator dependent and who was admitted with bacterial pneumonia eight days ago B. An adolescent with a positive HIV test and who was admitted for acute cellulitis of the lower leg 48 hours ago C. A newly diagnosed diabetic client with antibiotic induced diarrhea admitted 24 hours ago D. An older adult client with a history of hypertension, hypercholesterolemia and lupus, and who was admitted with Stevens-Johnson syndrome that morning
A. A middle-aged client with a seven-year history of being ventilator dependent and who was admitted with bacterial pneumonia eight days ago The best candidate for discharge is one who has a chronic condition and has an established plan of care. The client who has been on the ventilator for years is most likely stable and could continue medication therapy at home. The other clients have a risk for instability or are unstable.
The client, who is diagnosed with dementia, wanders throughout the long-term care facility. How can the nurse best ensure the safety of a client who wanders? A. Attach a monitoring band to the client's wrist B. Explain the risk of walking with no purpose C. Frequently reorient the client to time, person and place D. Apply a restraint to keep the client in a chair when awake
A. Attach a monitoring band to the client's wrist A wander management system is used to give people with dementia and other "at risk" clients the ability to move freely where they live. The sensor in the bracelet trips an alarm that's attached to exterior doors if the client attempts to leave the facility. It is inappropriate to use restraints or other restrictive devices to keep clients in chairs or beds (unless they are potentially harmful to themselves or others.) Reality orientation is inappropriate for someone with dementia.
The nurse understands that which situations require hand hygiene such as handwashing or hand sanitation? (Select all that apply.) A. Before having direct contact with a client B. After cleaning a wound C. After making an entry in the medical record D. Prior to and after eating E. After contact with objects in the immediate vicinity of the client
A. Before having direct contact with a client B. After cleaning a wound D. Prior to and after eating E. After contact with objects in the immediate vicinity of the client Handwashing is still the simplest and most effective strategy to prevent the spread of infection. It is necessary to wash one's hands to protect oneself prior to eating, after removing gloves following any client procedure and even after having contact with intact skin or objects in the client's room. However, it is not necessary to wash hands after handling every chart (although using an alcohol-based hand rub would be advisable).
The nurse is providing burn prevention education to parents of a toddler and a school-age child. What safety measures should the nurse include in the teaching? (Select all that apply.) A. Checks for hot straps or buckles before placing a child in a car seat B. Check a smoke detector when the alarm sounds C. Create an escape plan and practice it with the children D. Cook with pot handles turned towards the center of the stove E. Set the hot water heater at 130°F (54.4 C)
A. Checks for hot straps or buckles before placing a child in a car seat C. Create an escape plan and practice it with the children D. Cook with pot handles turned towards the center of the stove To prevent burns at home, hot water heaters should be set to below 120 F (48.8 C) and parents and caregivers should test the bath water before placing a child in it. When possible, the back burners on the stove should be used and pot handles should be turned to the center or toward the back of the stove to prevent an item from being pulled down by a child. A parent or caregiver should check the straps and buckles placing a child in a car seat. Escape plans should be practiced and children should know what to do in case of a fire. Smoke detectors batteries should be replaced regularly (usually once a year); people should not wait until the alarm sounds to replace the batteries.
A client arrives in the emergency department after a radiolgical accident at a local factory. After placing the client in a decontamination room, the nurse gives priority to which intervention? A. Ensure physiological stability of the client B. Double bag the client's contaminated clothing C. Wrap the client in blankets to minimize staff contamination D. Begin decontamination procedures for the client
A. Ensure physiological stability of the client The nurse must initially assist in the stabilization of a client prior to the performance of any other tasks related to radiologic contamination. A radiation survey meter reading above background radiation levels indicates the possibility of contamination. Radiologic contamination rarely results in loss of consciousness or immediate visible signs of injury. Thus, other causes of injury or illness should be ruled out.
A client with hepatitis A (HAV) is newly admitted to the unit. Which action(s) would be the priority to include immediately in the plan of care? (Select all that apply) A. Implement standard precautions B. Implement contact precautions C. Implement low calorie low fiber diet D. Implement a vaccine protocol E. Implement teaching on improved sanitation
A. Implement standard precautions B. Implement contact precautions Hepatitis A is transmitted though the ingestion of fecal matter, even in microscopic amounts, from close person-to-person contact and sexual contact with an infected person. Additionally, HAC can be transmitted through the ingestion of contaminated food or drinks. Implementation of standard and contact precautions are priority actions a nurse would implement upon admission for the protection of healthcare staff and visitors. Clients with Hepatitis A require a diet that is low in fat (fat is metabolized in the liver) but high in calories, carbohydrates and protein. The client should also eliminate all alcoholic beverages. Vaccine recommendations and breaking the chain of infection through improved sanitation is a teaching responsibility that will be addressed by the nurse before the client's discharge and will include the client and family/friends.
The nurse observes a nursing assistant using antiseptic hand sanitizer and rubbing their hands vigorously after leaving the room of a client diagnosed with Clostridium difficile (C-Diff). Which action by the nurse is appropriate? A. Instruct the nursing assistant to wash their hands again with soap and water. B. Instruct the nursing assistant to use bleach wipes to wipe off their hands. C. Praise the nursing assistant for proper use of antiseptic hand sanitizer. D. Report the nursing assistant to the infection control practitioner.
A. Instruct the nursing assistant to wash their hands again with soap and water. Anyone who is hospitalized should be encouraged to ask caregivers if they washed their hands and to remind visitors to wash their hands. However, it is the nurse's responsibility to supervise the nurse assistant and to correct practice errors as needed. C. diff is one of the few pathogens that require soap and water for cleansing the hands. Since antiseptic hand rub is ineffective against the hardy spores produced by this bacterium, the nurse should require the nursing assistant to wash their hands with soap and water, especially after providing care for this client.
A newly admitted client has a skin ulcer that tested positive for MRSA (methicillin-resistant Staphylococcus aureus). What precautions should the nurse take when caring for this client? (Select all that apply.) A. Keep all equipment in the client's room for their sole use. B. Place the client in a private room. C. Wear a mask while providing routine care to the client. D. Perform hand hygiene after contact with the client and before leaving the room. E. Keep the door to the room closed at all times F. Place personal protective equipment (PPE) at the door to the room
A. Keep all equipment in the client's room for their sole use. B. Place the client in a private room. D. Perform hand hygiene after contact with the client and before leaving the room. F. Place personal protective equipment (PPE) at the door to the room Contact precautions are recommended in acute care settings for MRSA when there is a risk for transmission or wounds that cannot be contained by dressings. The client should be in a single room. All equipment, such as stethoscopes and blood pressure devices, should be for the client's sole use and kept in the room. Health care workers must perform hand hygiene (wash hands with soap and water) after direct contact with the client and their environment and before leaving the isolation room. Contact precautions require health care workers to wear PPE such as gloves and a gown, which should be readily available. It is not required to keep the door closed at all times.
The medication benztropine mesylate (Cogentin) is ordered, but the nurse incorrectly administers carvedilol (Coreg). What are the most important actions the nurse should take after making this medication error? (Select all that apply.) A. Notify the nurse manager B. Notify the client C. Notify the health care provider D. Monitor and document the client's blood pressure E. Document the administration of carvedilol (Coreg)
A. Notify the nurse manager C. Notify the health care provider D. Monitor and document the client's blood pressure E. Document the administration of carvedilol (Coreg) When a nurse makes a medication error, the client's safety and well-being are the top priority. The nurse will document giving the beta-blocker carvedilol and as well as any effects the medication has on the client. The health care provider must be notified; the nurse will document that the provider was called and that orders were implemented. The nurse manager must also be notified. Once the client is stable, the nurse will complete an incident/variance/quality-assurance report (usually within 24 hours of the incident.) The initial disclosure of the medication error with the client should occur as soon as reasonably possible after the event (usually within 1-2 days after the event).
A client's wound has tested positive for Staphylococcus aureus (MRSA). What level of precaution should the nurse place the client on? A. Standard precaution and contact precaution B. Standard precaution and airborne precaution C. Contact precaution and airborne precaution D. Contact precaution and droplet precaution
A. Standard precaution and contact precaution Strep A Staphylococcus aureus is transmitted by skin to skin contact or contact with shared items or surfaces. Therefore, a client with MRSA will be put on contact precautions. Further, ALL clients will be on standard precautions at all times.
A nurse is preparing to enter a disaster scene. What assessment priorities must the nurse adhere to? (Select all that apply.) A. The nurse will allocate resources to those with the strongest probability of survival. B. The nurse will consider the age of a victim before allocating resources. C. The nurse will consult a physician prior to making client resource decisions. D. The nurse will obtain a certification before performing triage during a disaster. E. The nurse will assign a yellow color to a client that is stable and can wait for treatment. F. The nurse will assess clients by considering their airway, breathing, circulation and neurological function.
A. The nurse will allocate resources to those with the strongest probability of survival. F. The nurse will assess clients by considering their airway, breathing, circulation and neurological function. The goal of disaster triage is to use resources for clients with the strongest probability of survival. START triage is used in disaster scenes with mass causalities. Age is not a consideration when allocating treatment resources and the nurse does not need to consult a physician prior to making decisions about allocating resources. Further, a nurse does not need special training to assist in a disaster however there are certification available for those who are interested. Finally, the nurse will make decisions based on a client's airway, breathing, circulation and neurological function
The nurse is offering safety instructions to a parent with a 4 month-old infant and a 4 year-old child. Which statement by the parent indicates a correct understanding of the appropriate precautions to take with the children? A. "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while the 4 year-old naps on the sofa." B. "I have the 4 year-old hold and help feed the 4 month-old a bottle with me." C. "I place my infant in the middle of the living room floor on a blanket to play with my 4 year-old while I make supper in the kitchen." D. "I strap the infant car seat on the front seat to face backwards."
B. "I have the 4 year-old hold and help feed the 4 month-old a bottle with me." The infant seat should be placed on the rear seat. Small children and infants are not to be left unsupervised. Infants are to be placed on their back when they go to sleep or are lying in a crib. A four year-old could assist with the care of an infant such as feeding with proper direct supervision.
The parents of a toddler ask the nurse how long their child will have to sit in a car seat while in an automobile. What is the nurse's best response to the parents? A. "Your child must reach a height of 50 inches to sit in a seat belt." B. "Your child must use a car seat until he weighs at least 40 pounds." C. "The child must be five years of age to use a regular seat belt." D. "The child can use a regular seat belt when he can sit still."
B. "Your child must use a car seat until he weighs at least 40 pounds." The guidelines for car seats depend on the child's weight, height, age and car type. Children should use car seats until they weigh 40 pounds (according to the U.S. National Highway Traffic Safety Administration).
The charge nurse on the evening shift is asked to determine which client is a candidate for discharge. Which of these clients should the nurse select as a potential candidate for discharge? A. A young adult, admitted at the beginning of the shift, with an exacerbation of asthma B. A middle-aged adult with a history of type 1 diabetes and one day post diabetic ketoacidosis C. An adolescent, admitted on the day shift to rule out acute pancreatitis, who reports a history of alcohol abuse, with a current blood sugar of 90 D. An older adult female who is actively dying and has a "do not resuscitate" order
B. A middle-aged adult with a history of type 1 diabetes and one day post diabetic ketoacidosis The client selected to be discharged should be one whose condition is more stable than the others and where there's less of a risk for complications or instability after discharge. Although the client with asthma has a chronic condition, s/he was just admitted and is experiencing an acute exacerbation of the condition. The adolescent is experiencing an acute condition, probably brought on by his/her alcohol abuse. Neither of these clients are stable enough for discharge. It is a humane choice to allow the client who is in the process of dying to stay in the hospital.
The nurse is caring for a client who is not oriented to time, place or person and has repeatedly attempted to pull out intravenous lines and a feeding tube. The nurse receives an order from the health care provider to apply a vest and soft wrist restraints. Which of the following actions by the nurse are appropriate? (Select all that apply.) A. Release the restraints and provide care every four hours B. Conduct a thorough assessment of the client C. Document which alternative interventions were used or attempted D. Tie the restraints using quick-release knots E. Call the health care provider every 48 hours for a new order F. Explain the rationale for restraints to the client
B. Conduct a thorough assessment of the client C. Document which alternative interventions were used or attempted D. Tie the restraints using quick-release knots F. Explain the rationale for restraints to the client Prior to applying restraints, the nurse must first conduct a thorough assessment of the client and document the behavior and/or events leading to the use of the restraint. The nurse should also document which alternatives to restraints were tried and the client's response to those measures. Even though the client may be confused, the nurse must still explain the reason for applying restraints. A physician's order is required and the order must be renewed each calendar day of use. Many policies state that clients in restraints must be assessed every hour; care is given and documented at least every 2 hours.
The school nurse is providing information for teachers at a school where a 10 year-old child with epilepsy attends. What is the most important action a teacher can take when the child experiences a tonic-clonic seizure in the classroom? A. Provide privacy and reassure the other children B. Place something soft and flat under the child's head C.Note the sequence of movements with the time lapse of the event D. Clear the immediate area of anything that could harm the child
B. Place something soft and flat under the child's head During seizure activity, the priority would be to protect the child from physical injury. The teacher could place something soft and flat, like a folded jacket under the child's head to help prevent head trauma. After protecting the head, the prioritized sequence of the actions would be to move furniture away from the child, note movements and time, and then provide privacy, if possible, while reassuring the other students.
Mass casualty survivors are brought to the emergency department (ED) after a disaster. The nurse is assigned to four clients who were triaged in the field and have just arrived in the ED. Which client will the nurse care for first? A. The person with multiple wounds and an open fracture B. The person with hypotension and a sucking chest wound C. The person with head trauma requiring mechanical ventilation D. The person with an undisplaced fracture of the radius
B. The person with hypotension and a sucking chest wound Typically, the tab colors used in triage are black, yellow, green and red. Red-tagged clients have immediate threats to life and require care right away; this would be the survivor with hypotension and a sucking chest wound. Yellow-tagged clients have major injuries that need treatment within 30 minutes to two hours (the client with the open fracture), and green-tagged client have injuries that can be delayed more than two hours (the closed fracture). Black-tagged clients are treated last during a mass casualty situation because there is little chance for survival.
A client is diagnosed with gastroenteritis, caused by a salmonella infection. Which of these actions is the primary nursing intervention designed to limit the transmission of salmonella? A. Isolate the client in a single room without a roommate B. Wash hands thoroughly with soap and water before and after client contact C. Wear two pairs of gloves when changing contaminated linens D. Decontaminate hands with alcohol-based skin disinfectant after client contact
B. Wash hands thoroughly with soap and water before and after client contact Salmonella is a bacteria and one of the causes of gastroenteritis. Gastroenteritis is characterized by acute onset of nausea, vomiting, abdominal cramps and/or diarrhea. The CDC recommends using standard precautions for this illness, which is why the primary nursing intervention is thorough handwashing before and after client contact using soap and water. Skin disinfectants can reduce the number of bacteria on the hands but cannot replace the importance of washing with soap and water. Clients do not need to be placed in isolation; symptomatic clients can be cohorted. Double-gloving can be effective in surgery, but it's probably not needed when changing contaminated linens.
A nurse is conducting a community-wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning? A. A 9 month-old who stays with a sitter five days a week B. A 15 year-old who likes to repair bicycles C. A 20 month-old who has just learned to climb stairs D. A 10 year-old who occasionally stays at home unattended
C. A 20 month-old who has just learned to climb stairs Toddlers, aged one to three years, are at the highest risk for poisoning because they are increasingly mobile, need to explore and engage in autonomous behavior.
The paramedics are transporting a poisoning victim to the local hospital. In which of these cases does the nurse anticipate that hyperbaric oxygen therapy will be used? A. A 6 year-old found sitting on the bathroom floor beside an empty bottle of diazepam (Valium) B. A 21 year-old with suspected ethanol intoxication C. A 35 year-old found unconscious with suspected carbon monoxide poisoning D. A 2 year-old who ate an undetermined amount of crystal drain cleaner
C. A 35 year-old found unconscious with suspected carbon monoxide poisoning Carbon monoxide (CO) poisoning is the leading cause of poisoning in the U.S. It causes severe hypoxia which is why treatment includes high-dose oxygen; in severe poisoning, hyperbaric oxygen therapy may be used. Treatment for crystal drain cleaner and diazepam may include gastric lavage and/or activated charcoal. Treatment for alcohol poisoning may include gastric lavage, IV fluids and supportive care.
A nurse is performing well-child assessments at a day care center when a staff member interrupts the examinations for assistance with another child. The nurse finds a crying 3 year-old child on the floor with bleeding gums and two unlabeled open bottles nearby. What should be the nurse's first action? A. Administer syrup of Ipecac to induce vomiting B. Call the poison control center and then 911 C. Ask the staff member about the contents of the bottles D. Give the child milk to coat the stomach
C. Ask the staff member about the contents of the bottles The nurse needs to assess the situation and determine what the child ingested. Once the substance is identified, the poison control center and emergency medical services should be called
A neonate is having difficulty maintaining a temperature above 98 F (36.6 C) and is placed in an infant warming system (IWS). Which of the following actions will ensure the safety of the neonate? A. Warm all medications and liquids before administration B. Avoid touching the neonate with cold hands C. Monitor the neonate's temperature continuously D. Wrap the neonate snugly in a cotton blanket
C. Monitor the neonate's temperature continuously When using a warming device, the neonate's temperature should be continuously monitored using a probe that's securely attached to the skin. Monitoring the neonate's temperature is the priority safety concern because skin burns, permanent brain damage or even death can result due to improper use or monitoring of equipment. No clothing or swaddling is needed in the IWS; usually babies are dressed only in a diaper (although bubble wrap blankets or plastic wrap blankets can be used to minimize heat loss in high risk newborns.) For healthy term newborns, nurses should warm their hands and stethoscopes prior to contact with the baby.
After an explosion at a factory, one of the employees approaches the nurse and says, "I am a certified nursing assistant (CNA) at the local hospital." Which of these tasks would be appropriate for the nurse to assign to this worker who is assisting in the care of the injured? A. Check alertness B. Take temperatures C. Palpate pulses D. Measure blood pressure
C. Palpate pulses The heart rate and regularity would indicate if the client is in shock or has potential for shock. If the pulses could not be easily palpated or are irregular, those clients would need to be seen first and further assessment by the nurse could be done (including measuring blood pressure). Taking temperatures is not a priority in this situation.
The nurse is to administer a new medication to a client. Which of the following actions best demonstrates an awareness of safe and proficient nursing practice? A. Verify the order for the medication. Prior to giving the medication the nurse should say, "Please state your name." B. Prior to administration of the medication the nurse should ask: "What is your name?" then check the client's name band. C. Prior to administration of the medication, the nurse should ask: "What is your name? What allergies do you have?" and then check the client's name band and allergy band. D. Verify the client's allergies on the admission sheet and order. Verify the client's name on the name plate outside the room. Prior to the administration of the medication, ask the client, "What is your date of birth?"
C. Prior to administration of the medication, the nurse should ask: "What is your name? What allergies do you have?" and then check the client's name band and allergy band. A dual check is always done for a client's name. This would involve verbal and visual checks. Because this is a new medication an allergy check is appropriate. The other options have parts that might be correct actions. However, to be the correct answer all of the parts of an option need to be correct.
The nurse is checking on clients in the unit. Which of these findings indicates that an infusion pump set to deliver a morphine drip basal rate of 10 mL per hour, plus PRN dosages for breakthrough pain, is not functioning correctly? A. The client states: "I just can't get relief from my pain." B. The level of the drug is 100 mL at 9 am and is 50 mL at 12 noon C. The level of the drug is 100 mL at 8 am and is 80 mL at 12 noon D. The client complains of discomfort at the IV insertion site
C. The level of the drug is 100 mL at 8 am and is 80 mL at 12 noon The minimal dose is 10 mL per hour, which would mean 40 mL is given in a four-hour period. If any PRN doses were given then less would be in the bag. Minimally, 60 mL should be left at 1200 (12 Noon). The pump is not functioning when more than expected medicine is left in the container.
The nurse is caring for a client with a chest injury that required a chest tube placement. The client is confused and pulls out the chest tube as the physician has just finished replacing it. The nurse applies soft restraints on the client's wrist. Is this an appropriate nursing action? A. Yes, the nurse finds it difficult to have a confused client on the floor. B.No, the nurse needs an order from the physician before the restraints can be applied. C. Yes, the nurse can apply a restraint to protect the client from injury or harm, then obtain an order. D. No, the nurse can only apply restraints in the emergency room.
C. Yes, the nurse can apply a restraint to protect the client from injury or harm, then obtain an order. Under the Omnibus Budget Reconciliation Act, clients have the right to be from physical or chemical restraints imposed for the purpose of discipline or convenience. A soft wrist restraint can be applied before a doctor order is given, however the nurse must contact the physical immediately after the restraint is applied for a signed order. Finally, restraints can be applied in multiple health care settings and is not limited to an emergency room department if the patient may cause injury or harm themselves.
A severely injured client is moved into an examination area of the emergency department. The family member who accompanied the client to the ED is screaming at the nurse, saying that someone better start doing something right away. What is the best response by the nurse? A. "I need you to go to the waiting area. You can come back when you're more in control." B. "I'm going to give you a few minutes alone so you can calm down." C. "I can't think when you are yelling at me. Talk to me in a normal voice." D. "I know you are upset. But please control yourself and sit down. Otherwise I will have to call security."
D. "I know you are upset. But please control yourself and sit down. Otherwise I will have to call security." Most violent behavior is preceded by warning signs, such as yelling or swearing. The challenge for nurses is to apply interventions that de-escalate a person's response to stressful or traumatic events. The keys to effective limit setting are using commands to express the desired behavior and providing logical and enforceable consequences for noncompliance. Nurses should acknowledge the agitated person's feelings and be empathetic, reminding him or her that they are there to help.
The charge nurse is making client room assignments. In order to minimize the risk of a hospital acquired infection, which of these children would be the most appropriate roommate for a 3 year-old child diagnosed with minimal change disease? A. 3 year-old with a fracture whose sibling has Fifth disease B. 6 year-old with sickle cell disease experiencing a vaso-occlusive crisis C. 2 year-old diagnosed with a respiratory infection D. 4 year-old with bilateral inguinal hernia repair
D. 4 year-old with bilateral inguinal hernia repair Minimal change disease is a kidney disorder that can lead to nephrotic syndrome. Corticosteroids can cure the disease in most children but cytotoxic therapy and other drugs may be needed, but this treatment can reduce the child's ability to fight infection. The charge nurse must select a roommate who does not have an infection, which is the child who just had surgery. The sickle cell crisis may have been triggered by an infection. The child who's sibling has a viral disease has the potential to develop an infection.
The nurse is setting up a client's dinner tray. When the nurse turns her back to the client, the client grabs the nurse's buttocks and states he is hungry for much more than dinner. Which of the following responses by the nurse is indicated? A. Call the health care provider B. Quickly leave the room and ask the UAP to assist the client C. Ignore the behavior D. Complete an incident report
D. Complete an incident report To keep the therapeutic relationship intact, a nurse needs to set limits on appropriate behavior and not ignore bad behavior. Sexual harassment is a form of violence and is never part of the job. The nurse should report the incident to her supervisor and complete an incident report. The nurse has the right to ask not to be assigned to this client.
The clinic nurse assists the health care provider with physical examinations and the collection of laboratory specimens. Which of these findings should the nurse report to the public health department? A. Positive eye discharge confirming conjunctivitis B. Clinical findings of impetigo C. Skin scraping confirming the presence of ringworm D. Positive stool culture for shigella
D. Positive stool culture for shigella The Centers for Disease Control and Prevention (CDC) have a list of notifiable infectious diseases that is updated yearly. Shigellosis is the only reportable infection of those listed. Shigella are bacteria that can infect the digestive tract and cause (painful) diarrhea, cramping, vomiting, nausea; in severe cases it can cause seizures and kidney failure. Ringworm is a contagious fungal infection. Impetigo is a contagious, superficial bacterial skin infection. Conjunctivitis has many causes and is usually diagnosed from signs and symptoms and patient history.
A client is admitted to an inpatient crisis unit with the diagnosis of acute mania and has been placed in seclusion. The nurse is assigned to observe the client at all times. It is now time for the client's dinner. What action should the nurse take next? A. Accompany the client to the dining area and maintain observation B. Hold the meal until after the seclusion order has been discontinued C. Obtain a contract for safe behavior before accompanying the client to the dining area D. Serve the dinner in the seclusion room, maintaining observation
D. Serve the dinner in the seclusion room, maintaining observation Seclusion is ordered by a physician and requires continuous observation, unless the order is discontinued or amended. It is incorrect to amend the seclusion or mealtime. Meals can be eaten in the seclusion room with the nurse continuing the 1:1 observation. Meals must be offered on time and should not be withheld. Contracts for safe behavior are meaningless in the presence of psychotic behavior (mania).
A client falls while in the nurse's care. What is the appropriate action the nurse should take first once the client is safe? A. The nurse will investigate the incident before reporting it B. The nurse will call a family member to report the incident C. The nurse will not report the incident because the patient was not injured D. The nurse will report the incident and fill out an incident report
D. The nurse will report the incident and fill out an incident report Once the client is safe, it is the nurse's responsibility to report the incident and fill out an incident report. Each health care organization has their own policy and procedure. It is not the job of the nurse to investigate the incident. Each health care organization has appointed individuals that investigate incidents. Further, even if the client was not injured or harmed during the incident, the incident still needs to be reported and an incident report needs to be completed. Finally, the nurse may call a family member but it is not first action they should take. Again, consult your policy and procedure manual for reporting sequence.
Medical asepsis destroys all microorganisms and their spores. True or False?
False Medical asepsis helps prevent the transmission of microorganisms and surgical asepsis destroys all microorganisms and their spores.
The three elements of radiation protection are time, distance and shielding. True or false?
True The farther away you are from a radiation source, the less exposure; as a rule, if you double the distance, you reduce the exposure by a factor or four. The amount of radiation exposure typically increases with the time people spend near the source of radiation.
