NMNC 1110 EAQ 10: Safety and Infection Control (Mastery)

After the nurse educator finishes teaching a group of new staff nurses about postoperative care of the vascular bypass client, which statement by the new nurse indicates that more education is needed?

"A client report of throbbing pain typically indicates vascular reocclusion."

The parent of a toddler who is being treated for iron toxicity asks the nurse why induced vomiting is being used instead of activated charcoal. Which rationale would the nurse provide?

"Activated charcoal does not absorb iron."

The parents of a child diagnosed with hepatitis A express concern that other family members may contract hepatitis because they only have one bathroom. Which response would the nurse reply?

"All family members, including your child, need to wash their hands after using the bathroom."

The nurse is teaching participants in a prenatal class regarding breast-feeding versus formula feeding. A client asks, "What is the primary advantage of breast-feeding?" Which response is most appropriate?

"Breast-fed infants have fewer infections."

Which would the nurse teach the parent of an infant who is at risk for infections?

"Breast-feeding will provide protection against bacteria."

Which statement shows that the newly diagnosed asthma patient understands how to use a peak expiratory flow meter (PEFM)?

"I have to blow out as fast and hard into the machine as I can."

Which nursing intervention indicates misinformation when providing care for clients with the human immunodeficiency virus (HIV) infection?

"I will ask the client to avoid involvement in community activities."

After the nurse provides education about all-terrain vehicle (ATV) safety for a parent of a 11-year-old child, which statement made by the parent indicates an understanding of the information?

"I will make sure my child does not get on an ATV."

After the nurse has taught a client about a 2-gram sodium diet, which client statement indicates that the teaching has been effective?

"I will read labels on prepackaged food products before purchase."

Which statement made by the parent of a child with a physical illness poses a safety risk to the child?

"I will send the prescription to school in an airtight container."

Which statement by parents indicates that teaching has been effective regarding their child's pinworm infestation?

"I'll have to reinforce her hand-washing habits before she handles food."

The nurse is providing instruction to a parent of a child with influenza. Which statement by the parent indicates the need for further instruction?

"I'll manage the fever with baby aspirin."

A 15-month-old child is hospitalized after ingesting toilet bowl cleaner. The mother confides that she feels guilty about leaving the cleaner where her child could get it. Which is the best response by the nurse?

"It was an accident, but you should consider special locks on your closets."

A parent calls the school nurse to ask how to check for head lice. Which instruction would the nurse provide?

"Look at your child's head along the scalp line for white dots."

Which statement made by the nurse requires correction when discussing registered nurse licensure in the United States with peers?

"Passing the NCLEX-RN® examination indicates maximal knowledge base for safe nursing practice."

A burn client is receiving the open method for wound treatment. Which information will the nurse explain to the client?

"Personal protective equipment will be worn by staff."

The nurse explains to the parents of a 6-year-old child with a pinworm infestation how pinworms are transmitted. Which statement indicates that the teaching has been understood?

"She needs to wash her hands before eating anything."

The nurse is being treated for a needlestick injury. Which instruction would the nurse be given to decrease the risk of seroconversion while taking combination antiretroviral therapy (cART)?

"Start medication within 24 to 36 hours."

A client expresses concern regarding the lack of annual flu vaccines because of a supply and demand problem. Which response by the nurse is best?

"There are other things you and your family can do to prevent the flu, such as hand washing."

Which statement by the nurse explains the reason clients prescribed corticosteroid therapy for a chronic health problem develop frequent infections?

"They affect antigen-antibody immunity."

A new mother asks the nurse administering erythromycin ophthalmic ointment to her newborn why her baby must be subjected to this procedure. Which is the best response by the nurse?

"This antibiotic helps keep babies from contracting eye infections."

Which statement would the nurse include in the teaching plan of a client anticipating discharge with acquired immunodeficiency syndrome (AIDS)?

"Wash used dishes in hot, soapy water."

Which statement indicates the patient understands the origin of hepatitis C?

"You can catch it while you're getting a tattoo."

When a client with a health care-acquired respiratory tract infection asks the nurse what this means, which response will the nurse give?

"Your infection occurred because of exposure to a health care facility. "

An older client asks, "How do I know that the medications that I take are safe?" Which response by the nurse is correct? Select all that apply. One, some, or all responses may be correct.

- "Ask your health care provider how and when you should be taking your medications." - "Check the name, dose, and instructions about administration of medications each time before leaving the pharmacy." - "Inform your health care provider of the over-the-counter medications, recreational drugs, and amount of alcohol you ingest."

The mother of a preschooler reports to the nurse that her child has started wetting the bed after previously being dry throughout the night. Which questions would be appropriate for the nurse to ask? Select all that apply. One, some, or all responses may be correct.

- "Does your child have an illness?" - "Is there a new sibling in the family?" - "Did you recently move to a new home?"

Which situations come under the second level of Maslow's hierarchy of needs? Select all that apply. One, some, or all responses may be correct.

- A client tells the nurse that he or she is taunted by his or her boss every day. - A client tells the nurse that his or her spouse belongs to a criminal gang. - A client tells the nurse that he or she lives beside a factory that manufactures harmful chemicals.

The nurse is admitting a client with severe myxedema coma. Which interventions would the nurse include in the plan of care? Select all that apply. One, some, or all responses may be correct.

- Administer intravenous (IV) levothyroxine. - Giving IV normal saline

The nurse suspects stage I seminoma in a client with Klinefelter syndrome. Which diagnostic tests would be helpful in further evaluating the mass? Select all that apply. One, some, or all responses may be correct.

- Alpha fetoprotein - Lactase dehydrogenase - Beta human chorionic gonadotrophin

The nurse is working with a group of clients in a mental health facility. The nurse would assess risk for suicide in clients with which conditions? Select all that apply. One, some, or all responses may be correct.

- Anxiety - Alcohol abuse - Schizophrenia - Bipolar disorder

Which side effect would the nurse monitor for when administering a selective serotonin reuptake inhibitor (SSRI)? Select all that apply. One, some, or all responses may be correct.

- Anxiety - Nausea - Sedation - Restlessness - Suicidal ideation - Increased energy level

Which finding during a home health visit would prompt the nurse to provide a client with home safety instructions? Select all that apply. One, some, or all responses may be correct.

- Area rugs on the floor - Clogged, dirty fireplace - Multiple electrical cords - Multiple prescribed medications - Wheeled walker with uneven legs

Which steps are included in the emergency treatment of poisoning in a toddler? Select all that apply. One, some, or all responses may be correct.

- Assess the victim. - Identify the poison. - Terminate the exposure. - Prevent poison absorption.

Which instruction on infection prevention would the nurse include when providing discharge education to a client who received a cadaveric renal transplant? Select all that apply. One, some, or all responses may be correct.

- Avoid eating from buffets. - Obtain annual flu vaccinations. - Perform regular hand hygiene. - Stay away from crowded areas. - Report a temperature greater than 100.5°F.

Which birth factors place the neonate at risk for sudden infant death syndrome (SIDS)? Select all that apply. One, some, or all responses may be correct.

- Birth order - Multiple births - Low Apgar scores

Which assessment finding would the nurse question for a client who is considering oral contraceptives? Select all that apply. One, some, or all responses may be correct.

- Blood clots - Heart disease - Breast cancer - Impaired liver function - Undiagnosed vaginal bleeding - Smoking more than 15 cigarettes per day

Which information would the nurse discuss with a group of adolescents wearing orthodontic appliances to prevent infection? Select all that apply. One, some, or all responses may be correct.

- Brushing teeth twice a day - Flossing after each meal - Visiting the dentist twice a year - Drinking unsweetened drinks - Cleaning around orthodontic gear

Which information would the nurse include when educating a group of daycare workers on infection control guidelines? Select all that apply. One, some, or all responses may be correct. 1

- Cleaning toys - Hand hygiene - Food preparation

Which action would the nurse include when instructing a group of 6-year-olds on illness prevention? Select all that apply. One, some, or all responses may be correct.

- Covering your cough - Washing your hands often - Throwing tissues away - Getting plenty of sleep - Avoiding sharing drinks

Which clinical manifestations indicate to the nurse that the client has an inadequate fluid volume? Select all that apply. One, some, or all responses may be correct.

- Decreased urine - Hypotension - Dry mucous membranes - Poor skin turgor

Which characteristics of a bully would the nurse include in parental education? Select all that apply. One, some, or all responses may be correct.

- Defiant - Aggressive - Manipulative

Which are the leading causes of accidental death in infants under 1 year of age? Select all that apply. One, some, or all responses may be correct.

- Drowning - Suffocation - Motor-vehicle related injury

Which are examples of internal disasters that must be accounted for when formulating a disaster response plan? Select all that apply. One, some, or all responses may be correct. Correct 1

- Fire - Power outage

The nurse is providing colostomy care to a client with methicillin-resistant Staphylococcus aureus (MRSA) infection. Which personal protective equipment (PPE) would the nurse use? Select all that apply. One, some, or all responses may be correct.

- Gloves - Gown - Goggles

Which substance can cause life-threatening dysrhythmias when inhaled? Select all that apply. One, some, or all responses may be correct.

- Glue - Gasoline - Paint thinner

Which safety topic would the nurse include when providing information to parents of an 8-year-old regarding bicycle safety? Select all that apply. One, some, or all responses may be correct.

- Helmet use - Hand signals - Crossing signs - Reflective lights - Close-toed shoes

Which laboratory value would the nurse assess when preparing a client for a renal biopsy? Select all that apply. One, some, or all responses may be correct.

- Hematocrit - Hemoglobin - Platelet count - Prothrombin time (PT) with international normalized ratio (INR) - Partial thromboplastin time (PTT)

Which cause may produce abnormal uterine bleeding? Select all that apply. One, some, or all responses may be correct.

- Hypothyroidism - Failure to ovulate - Bleeding disorders - Unidentified pregnancy - Use of oral contraceptives - Benign lesions of the uterus

Which action would the nurse perform when preparing to administer medication to a 4-year-old in a day care center? Select all that apply. One, some, or all responses may be correct.

- Identifying the child - Verifying the dosage - Reviewing the side effects - Obtaining parental consent - Ensuring that the medication is taken

Which actions by the staff of a mental health unit can lead to client violence? Select all that apply. One, some, or all responses may be correct.

- Inconsistent limit setting - Controlling staff members - Randomly taking away privileges

Which information would the nurse include when educating the parents of a 10-month-old about accidental poisoning? Select all that apply. One, some, or all responses may be correct.

- Keep poison control number handy. - Avoid storing chemicals in containers also used to keep food.

Which nursing interventions are the most appropriate to prevent further injury in the client who was injured in a hurricane and now is confused? Select all that apply. One, some, or all responses may be correct.

- Keeping the side rails up on the stretcher - Maintaining adequate lightening in the room - Asking a family member to remain with the client - Reminding the client to use the call light for assistance

Which items would the nurse need when caring for a client undergoing treatment from an internal radiation implant that has become dislodged? Select all that apply. One, some, or all responses may be correct.

- Lead-lined container - Long-handled forceps

Which disease process places a client at increased risk for infection? Select all that apply. One, some, or all responses may be correct.

- Leukemia - Lymphoma - Emphysema

Which risk factor increases a client's risk for infection in the community? Select all that apply. One, some, or all responses may be correct.

- Lifestyle - Occupation - Frequent traveling

Which substance history of a severe allergic reaction results in avoidance of the cephalosporins such as cefazolin, cefditoren, cefotetan, and ceftriaxone? Select all that apply. One, some, or all responses may be correct.

- Milk - Aspirin - Calcium - Penicillin

Which intervention would the nurse use for a client with full-thickness burns to the chest and anterior right arm? Select all that apply. One, some, or all responses may be correct.

- Monitoring vital signs - Cutting off the clothing - Inserting a urinary catheter - Removing the client's jewelry - Establishing an intravenous line

Which diseases would the nurse include when teaching parents about viruses? Select all that apply. One, some, or all responses may be correct.

- Mumps - Measles - Hepatitis B

Which threats included in the term "NBC" lead to the implementation of improved emergency medical services (EMS) and hospital safety programs? Select all that apply. One, some, or all responses may be correct.

- Nuclear - Biological - Chemical

Which medication would the nurse instruct a client to avoid while taking alprazolam? Select all that apply. One, some, or all responses may be correct.

- Opiods - Alcohol - Barbiturates

Which emergency medical system (EMS) first responders can perform triage during mass casualty incidents? Select all that apply. One, some, or all responses may be correct.

- Paramedics - Nurse appointed to a field team

Which foods increase the risk of aspiration or are choking hazards for toddlers? Select all that apply. One, some, or all responses may be correct.

- Peas - Nuts - Hot dogs

Which infection control measures would the nurse provide a client regarding blood glucose monitoring? Select all that apply. One, some, or all responses may be correct.

- Perform hand washing - Clean site before fingerstick

Which features would the emergency department (ED) nurse use from an automated tracking system for triage during mass casualty incidents (MCIs)? Select all that apply. One, some, or all responses may be correct.

- Priority upon arrival - Interaction with caregivers - Priority per process of care - Priority according to location

Which safety intervention would the nurse include in a plan of care for a client with somatic disorder who reports loss of vision? Select all that apply. One, some, or all responses may be correct.

- Put the call light within reach. - Orient client to surroundings.

The nurse listens to and validates the feelings expressed by a confused older adult. Which element(s) would the nurse convey in this situation? Select all that apply. One, some, or all responses may be correct.

- Respecting - Reassuring - Understanding

Which intervention would the nurse use to prevent injury to others when caring for a client with intermittent explosive disorder? Select all that apply. One, some, or all responses may be correct.

- Set limits and expectations. - Provide structure and boundaries. - Ignore attention-seeking behaviors.

Which actions transmit the human immunodeficiency virus (HIV)? Select all that apply. One, some, or all responses may be correct.

- Sharing syringe needles - Breast-feeding a newborn - Anal intercourse

Which nursing resource must be available to effectively meet potential needs during a disaster? Select all that apply. One, some, or all responses may be correct.

- Staff - Medication - Hospital beds - Mechanical ventilators - Personal protective equipment

Which safety information would the nurse instruct parents to review when selecting a daycare? Select all that apply. One, some, or all responses may be correct.

- Staff-child ratios - Sanitary conditions - Emergency protocols

Which information regarding risks that may result from an untreated chlamydia infection would the nurse include when providing education for a female client? Select all that apply. One, some, or all responses may be correct.

- Sterility - Ectopic pregnancy - Blocked Fallopian tubes - Pelvic inflammatory disease - Increased likelihood of HIV infection

Which conditions are given a green tag according to triage disaster tag system? Select all that apply. One, some, or all responses may be correct.

- Strains - Abrasions

Which information would the nurse include when working with the parents of a toddler regarding bathroom safety? Select all that apply. One, some, or all responses may be correct.

- Supervise all time in the bathtub. - Install a lock for the toilet bowl lid. - Remove electronics from the bathroom. - Test the water temperature before getting in the tub. - Keep a basket with soap and shampoo close.

Which sexually transmitted infections are caused by bacteria? Select all that apply. One, some, or all responses may be correct.

- Syphilis - Gonorrhea

Which information would the nurse provide an older adult and caregivers regarding medication safety? Select all that apply. One, some, or all responses may be correct.

- Use a pill organizer. - Read all medication labels. - Review medications with pharmacist.

Which information would the nurse include in a community education session on decreasing the risk for musculoskeletal injuries? Select all that apply. One, some, or all responses may be correct.

- Use of seatbelts - Obeying speed limits - Wearing safety equipment - Avoiding impaired vehicle use - Refraining from distracted driving

When the registered nurse (RN) assigns the unlicensed assistive personnel (UAP) to obtain and record routine vital signs on all clients on the unit, what should the RN be sure to do? Select all that apply. One, some, or all responses may be correct.

- Validate willingness to accept the delegated task. - Convey unique client requirements, characteristics, or concerns. - State the exact task, how it is to be accomplished, and expected outcomes. - Specify concerns or emergency conditions that warrant prompt reporting.

Which behavior is an early sign of an abusive personality? Select all that apply. One, some, or all responses may be correct.

- Verbal abusive - Jealous, controlling - Enforces rigid sex roles - Hypersensitive, easily insulted - Isolates partner from family and friends - Makes others responsible for their feelings

The nurse is preparing to administer methylphenidate to an older adult with apathy and depression. Which would the nurse include in the assessment to monitor for complications? Select all that apply. One, some, or all responses may be correct.

- Vision - Weight - Heart rate

Which instruction would the nurse include when teaching the client how to perform peritoneal dialysis and the importance of preventing peritonitis? Select all that apply. One, some, or all responses may be correct.

- Wear a mask during the procedure. - Clean the catheter exit site every day. - Maintain meticulous aseptic technique. - Wash your hands before the exchange. - Store supplies in a clean and dry location.

Which action would the nurse include in the plan of care for a client who had an ischemic stroke caused by atrial fibrillation and has been placed on anticoagulation therapy to prevent further strokes from occurring? Select all that apply. One, some, or all responses may be correct.

- Wearing a medical alert bracelet - Refraining from estrogen therapy - Initiating bleeding precautions - Obtaining routine prothrombin times - Notifying providers of anticoagulation

The nurse is reviewing the medical record of a client taking lithium for the management of bipolar disorder. Which finding indicates safe therapeutic levels of the medication?

0.7mEq/L

Arrange the events of an examination of a rape victim for a sexually transmitted infection in correct order.

1 Nucleic acid amplified testing for chlamydia and gonorrhea 2 Wet mount and culture or point-of-care testing of a vaginal swab specimen for trichomoniasis 3 Serum sample for HIV infection, hepatitis B, and syphilis 4 Repetition of serological tests for syphilis and HIV infection

In which order would clients receive care based on triage tag color?

1 Red 2 Yellow 3 Green 4 Black

When preparing to administer medications safely to a pediatric client, the nurse would recognize which as the minimum age that pharmacokinetic parameters in pediatric clients become similar to those in an adult?

1 year

By which age should an infant have had his or her first dental examination?

12 months

A prescription is written for famotidine 20 mg intravenous piggyback (IVPB) every 12 hours. The vial is labeled 10 mg/1 mL. How many milliliters will the nurse administer? Record your answer using a whole number. ___ mL

2

At which height is it no longer safe for a toddler to sleep in a crib?

36 inches

The intake and output of a client over an 8-hour period (from 0800 to 1600) is as follows: 150 mL urine voided at 0800; 220 mL urine voided at 1200; 235 mL urine voided at 1600; 200 mL gastric tube formula + 50 mL water administered initially and then repeated × 2; IV had 900 mL in the bag at 0800, and 550 mL remains in the bag at 1600. What is the difference between the client's intake and output? Record your answer using a whole number. ___ mL

495

When preparing to administer medications safely, it is important for the nurse to remember at which age an infant's gastric emptying time reaches adult values?

6 to 8 months

Penicillin G benzathine suspension 2.4 million units is prescribed for a client. The medication is available in a 10-mL multidose vial in which 1 mL = 300,000 units. How many milliliters will the nurse administer? Record your answer using a whole number. ___ mL

8

At the beginning of the shift at 7:00 AM, a client has 650 mL of normal saline solution left in the intravenous bag, which is infusing at 125 mL/hr. At 9:30 AM the health care provider changes the IV solution to lactated Ringer solution, which is to infuse at 100 mL/hr. What total amount of intravenous solution would the client have received by the end of the 8-hour shift? Record your answer using a whole number. ___ mL

863

The nurse would instruct a client with type I diabetes to dispose of a used syringe in which container?

A plastic liquid detergent bottle with a screw-top lid

Which medication is safe to take during pregnancy? Select all that apply. One, some, or all responses may be correct.

Acetaminophen

Which intervention would the nurse use to promote the safety of a client experiencing alcohol withdrawal?

Administer chlordiazepoxide.

A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and reports right-sided chest pain. Which action would the nurse take first?

Administer oxygen using a face mask

A woman in active labor arrives at the birthing unit. She tells the nurse that she was told that she had a chlamydial infection the last time she visited the clinic; however, she stopped taking the antibiotic after 3 days because she "felt better." In light of this history, which would the nurse anticipate as part of the plan of care?

Administration of antibiotics before delivery

The nurse is caring for a client for whom segmental postural drainage treatments are prescribed. The nurse would avoid scheduling a treatment for which time?

After a meal

Which emergency response team is involved in emotional recovery of victims after a disaster?

American Red Cross

The nurse teaches a father how to provide oral care for his child who is undergoing chemotherapy. The nurse determines that he needs further teaching when he tries to use which dental hygiene product?

An electric toothbrush

Which reaction is an example of a type I hypersensitivity reaction?

Anaphylaxis

Which clinical condition is associated with lead poisoning?

Anemia

A client reporting a recent bee sting presents with localized redness, swelling, intense localized pain, and itching. Which action would the nurse implement?

Applying cold compresses to the affected area

Which action would the nurse use for a client who is rushing down the hall of the mental health unit, rapidly tapping his fingers against the wall? Correct 1

Approach the client in a nonthreatening manner to determine the cause of the agitation.

Which intervention would the nurse encourage the parents of a child with plumbism (lead poisoning) to do?

Assess the family's home environment for lead sources and have them removed.

The client with which tag color requires immediate treatment in the emergency department according to disaster triage tag system?

B (red)

Which statement accurately describes the current advice regarding breast self-examination (BSE)?

BSE should be taught to all women.

Which noninvasive assessment and management skills certification would the nurse be required to use for airway maintenance and cardiopulmonary resuscitation (CPR)?

Basic Life Support (BLS)

Which physical assessment situation is appropriate for use of alcohol-based hand sanitizer for hand hygiene?

Before and after palpating a pulse

The nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. Which step would the nurse do next after placing the nurse's arms under the client's axillae?

Bending and then straitening their knees

The nurse is preparing to administer an intramuscular injection to a newborn. To administer the injection safely, the nurse would be cognizant of which cause of slow absorption in newborns?

Blood flow

A client exhibits dysphasia, dry mouth, drooping eyelids, blurred vision, vomiting, and diarrhea. Within 24 hours, the client develops bilateral cranial nerve impairment and descending weakness. Which bioterrorism agent presents with these clinical manifestations?

Botulism

The nurse is caring for a client admitted with peritonitis. Which finding in the medical record is most likely the cause?

Bowel obstruction

Which certification course may be an elective for the nurse qualified to care for clients in a disaster-related emergency situation? Incorrect 1

Certified Emergency Nurse (CEN)

Which technique would the nurse employ for an obstetrical client with a foreign body airway obstruction?

Chest thrusts

For which client illness would airborne precautions be implemented?

Chickenpox

Which would the nurse use to perform hand hygiene when caring for an immunocompromised client?

Chlorhexidine

Which statement by the nurse is true regarding the disaster triage tag system?

Class II clients are marked with a yellow tag.

To which disaster triage class would the nurse infer a client with a green triage tag belongs?

Class III

Based on their conditions, which client would be triaged first according to the 3-tiered triage system? Client A - Chest pain Client B - Displaced or multiple fractures Client C - Renal colic Client D - Strains of sprains

Client A

Which client condition would require the highest priority for treatment among four clients admitted at the same time under mass casualty conditions? Client A - Massive head trauma Client B - Open fracture with a distal pulse Client C - Shock Client D - Strains and contusions

Client C

Which term describes the practice of placing clients with the same infection in a semi-private room?

Cohorting

Which nursing behavior is essential when working with leadership personnel during the activation of the emergency preparedness plan?

Collaboration

Which type of isolation precautions would the postpartum nurse plan to institute for a client who has delivered her infant by cesarean birth because of active genital herpes?

Contact

Which intervention would provide the greatest safety for a client admitted to a mental health unit because of suicidal ideation?

Continual one-on-one supervision

A child becomes cyanotic during a generalized tonic-clonic seizure. Which is the most appropriate action by the nurse?

Continuing to observe the fever

When discussing standards for involuntary admission to a mental health facility, which factor is related to safety?

Currently cutting

Which information would the nurse provide a client with a new colostomy about managing the appliance?

Cut opening 1/8- to 1/16-inch larger than stoma.

Which is the most effective professional leadership and management strategy nurses implement to improve safety and quality of patient-centered care?

Delegation

Which finding would lead the nurse to contact the state bureau of motor vehicles to obtain a driving evaluation for an older adult?

Dementia

The school nurse is planning to teach the importance of hand washing to the children in first grade. Which is the most effective approach for this age group?

Demonstrating hand washing and asking for return demonstrations

During disaster response, which task is the responsibility of the medical command physician? Select all that apply. One, some, or all responses may be correct.

Determine client acuity

Which team would be mobilized to manage the deceased at the earthquake zone where many people lost their lives?

Disaster Mortuary Operational Response Teams (DMORTs)

Which report by the client post transrectal prostate biopsy needs to be communicated to the health care provider as a possible sign of infection?

Discharge from penis

Which action would the nurse implement when providing care for a client with acquired immunodeficiency syndrome (AIDS)?

Discourage long visits from family members.

A client sustains severe burns over 40% of the surface area of the body. The nurse is assigned to care for the client during the first 48 hours after the injury. Which clinical finding would the nurse anticipate if the client develops water intoxication?

Disorientation with twitching

Which factor increases an adolescent's risk for injury in the community?

Distracted driving

Which action provides support for the fetal head as it is being delivered?

Distributing the fingers evenly around the head

The nurse should take which infection control measures when caring for a client admitted with a tentative diagnosis of infectious pulmonary tuberculosis (TB)?

Don an N95 respirator mask before entering the room.

Which training measure is most effective to adequately familiarize health care providers with emergency response procedures?

Drills

Which instruction would the nurse provide to a client who is concerned about contracting amebic dysentery during foreign travel?

Drink only bottled water

Who is responsible for triaging the victims of a multiple motor vehicle crash on a major interstate?

Emergency first responders

Which emergency staff member would monitor vital signs, perform basic wound care, and ensure spinal immobilization for a client admitted to the emergency department after a train derailment?

Emergency medical technicians

Which nursing action is appropriate when terminating exposure for a toddler who presents to the emergency department (ED) after eating a lily? Correct 1

Emptying the mouth

Which safety precaution would the nurse employ when assisting with the removal of a client's vaginal radium seeds?

Ensure long forceps are available for removing the radium.

Which would be included in the plan of care for an obstetrical client who has been taking carbamazepine throughout the first trimester of pregnancy?

Evaluation for neural tube defect

The nurse is caring for a client who has an implanted port. How often would the nurse change the noncoring needle?

Every 7 days

To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse would change the administration set how often?

Every 72 to 96 hours

Which finding during assessment prompts the nurse to don a protective gown?

Excessive wound drainage

Which example of indirect bullying would the nurse use when teaching a parent about bullying?

Exclusion

Which new triage level would the emergency department (ED) nurse training to be a member of a direct response team to respond to community emergencies be required to learn?

Expectant

The nurse provides discharge teaching to a client who had a total hip replacement. The client states that the plan is to go swimming at the community pool the day after discharge. Which action would the nurse take in response to the client's comment?

Explain that the incision should not be immersed in water until it has healed.

When assessing a client with Hepatitis A, the nurse is particularly careful with which substance to prevent transmission of the disease?

Fecal matter

Who would the nurse contact to receive training as a Community Emergency Response Team (CERT) member?

Federal Emergency Management Agency (FEMA)

When the staff nurse is called into work because the organization is experiencing an internal disaster, which scenario would the nurse expect when she or he arrives at work?

Fire in the information technology department

Which would the nurse describe as an example of an internal disaster?

Fire or explosion

A client admitted with a burn injury has erythema and mild swelling. Which type of burn would the nurse suspect?

First-degree burn

Which would the nurse state is an example of a natural disaster?

Floods

Which type of emergency assessment is being performed when the nurse is inserting a gastric tube and arranging for diagnostic studies for a client who sustained injuries after a bus accident?

Focused adjuncts

Which clinical finding is associated with strabismus?

Frequent squinting

Which method of delivering client care works well in disaster situations?

Functional nursing

Which initial nursing intervention would the nurse take for an older adult with delirium who begins acting out while in the dayroom?

Giving the client one simple direction at a time in a firm, low-pitched voice

Which color tag would the nurse use to triage a victim of a train derailment who is able to walk independently to the first aid station?

Green

Which disaster triage tag would the nurse find on victims of a mass causality event with minor injuries who arrived to a hospital in a private vehicle?

Green

Which unique adverse effect of pharmacotherapy is the pediatric population most at risk for?

Growth suppression

For clients with mental health disorders, which behavior is most important to prevent?

Harming themselves or others

Which training will help nurses identify signs of biological terrorism?

Hazardous materials (HAZMAT)

When a client who has just started a transfusion of packed red blood cells reports chest pain, flank pain, difficulty breathing, and chills, which complication would the nurse suspect?

Hemolytic reaction

Which is the facility-level organizational model for disaster management?

Hospital Incident Command System (HICS)

The nurse is caring for four postpartum clients, each with a different medical condition. Which condition will result in the primary health care provider advising the new mother not to breast-feed?

Human immunodeficiency virus (HIV) infection

A full-term infant who is large for gestational age (LGA) should be monitored for which risk?

Hypoglycemia

A mother diagnosed with acquired immunodeficiency syndrome (AIDS) states she has been caring for her baby even though she has not been feeling well. Which important information would the nurse determine regarding the care provided by the mother?

If the mother is breast-feeding her baby

Which characteristic aligns with prioritizing care into the triage level of "emergent"?

Immediate threat to life or limb

The nurse in the emergency department is caring for a 9-year-old child with a suspected spinal cord injury sustained while falling off a bicycle. Which is the initial nursing action?

Immobilizing the child's spine to limit additional injury

Which antibody forms first, after exposure to an antigen?

Immunoglobulin M (IgM)

The nurse is preparing to administer a transdermal medication to an infant. To administer the medication safely, the nurse would recognize which as the reason absorption is more rapid via the transdermal route in infants than in older children?

Increased blood flow

For which condition would an infant born with exstrophy of the bladder be at risk?

Infection

Which suicide method would indicate a low threat of lethality?

Ingesting pills

The nurse is preparing a child who has undergone a myringotomy for discharge. Which would the parents be taught about their child's care at home?

Insert earplugs whenever a bath is given.

Which assessment is necessary for the nurse to complete in a client with chronic kidney disease receiving loop diuretics?

Intake and output measurements

A client tells the nurse, "My legs begin to hurt after walking for several blocks. The pain goes away when I stop walking, but it comes back again when I resume walking." Which condition would the nurse consider as the most likely cause of the client's pain?

Intermittent claudication

Which rationale would lead the nurse to question an order for a tap water enema for a 6-month-old infant with suspected Hirschsprung disease?

It could cause a fluid and electrolyte imbalance.

The nurse is planning to teach the four-point alternate crutch gait to a 9-year-old child with cerebral palsy. How would the nurse explain this choice to the parents?

It provides for equal but partial weight bearing on each limb.

Which action would the nurse take when preparing to change a client's dressing using surgical asepsis?

Keep the area free of microorganisms.

Which topics will the nurse include when educating the parents of an adolescent on home safety?

Keeping firearms locked away

Which nursing objective would the nurse add to the plan of care for a child with attention-deficit/hyperactivity disorder (ADHD) who engages in self-destructive behavior?

Keeping the child from inflicting any self-injury

Which position increases cardiac output in the obstetrical client with cardiac disease?

Lateral positioning

Which method of swaddling could cause risk for injury?

Legs extended

Which lesion may alter skin turgor?

Lichenification

Which plant, if ingested by a preschool-age client, would necessitate further action by the nurse?

Lily

Which plant, if ingested by a toddler, would necessitate further action by the nurse?

Lily

Why should the use of baby powder on an infant be avoided?

Lung irritation

Which statement best describes the goal when the administrator of a skilled nursing facility reviews the organization's internal emergency management plan?

Maintain client, staff, and visitor safety.

A child swallowed a poisonous substance and has fallen unconscious. Which nursing intervention is advisable for the child?

Make arrangements for the child to be taken to a hospital.

Which public health risk became a major focus for hospitals after the September 11, 2001, terrorist attacks?

Mass casualty incidents (MCIs)

Which emergency medical service agency offers service such as first aid stations and special-need shelters during a disaster or pandemic disease outbreak?

Medical Reserve Corps (MRC)

Which medical relief team would the nurse expect to help health care facilities that face personnel shortages during a mass casualty event?

Medical Reserve Corps (MRC)

Which type of asepsis is the nurse using when he or she washes his or her hands before changing a client's postoperative dressing?

Medical asepsis

Which personnel would the nurse state are responsible for deciding the number, acuity, and resources needed for clients during a disaster?

Medical command physician

Which condition in a client with a brain injury is contraindicated for magnetic resonance imaging (MRI) with contrast?

Metal aneurysm clips

A client develops hemolytic anemia. Which client medication can cause this adverse effect?

Methyldopa

Which substance will the home care nurse instruct a client to use after laryngectomy to cleanse the stoma site?

Mild soap and water

Which medication for treatment of gastroesophageal reflux disease would be contraindicated in the pregnant client?

Misoprostol

Which element would the nurse focus on when teaching crutch-walking to a client who has a casted leg fracture?

Modifying the home environment to prevent accidents

Which nursing action would be included in the plan of care for a child with acute poststreptococcal glomerulonephritis?

Monitoring for seizures

Which action would the nurse take to decrease the risk of transmission of vancomycin-resistant enterococci (VRE)?

Move the client to a private room

Which type of needs would be placed as a high priority in the prioritization of client care?

Needs that affect safety

A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. Which type of room would the nurse assign this client?

Negative-airflow room

The nurse is caring for a surgical client who develops a wound infection during hospitalization. Which classification would this infection belong to?

Nosocomial

Which factor is the strongest predictor of illness in a childcare setting?

Number of unrelated children in the room

Which nursing-sensitive indicator can be used to evaluate the process of nursing care? Select all that apply. One, some, or all responses may be correct.

Nurse job satisfaction

When is it not necessary for the nurse to wear gloves while caring for a newborn?

Offering a feeding

Where is the blood pressure cuff placed on a client with a dialysis access fistula in the right arm?

On the left arm

Which statement describes the purpose of a community emergency response team (CERT)?

Organizes untrained volunteers to help victims after a disaster

When the nurse needs to determine atrial rate and rhythm, which component of the electrocardiogram will be used?

P waves

The nurse is caring for a client with suspected appendicitis. Which assessment finding would the nurse determine would further support the diagnosis?

Pain in right lower quadrant

Which cardiac disease has the lowest risk for maternal mortality?

Patent ductus arteriosus

Which is a primary contributing factor for the risk-taking behavior for school-aged children?

Peer pressure

Which information would the nurse provide to a client taking dulaglutide?

Perform self-injection weekly

Which effect has resulted in the avoidance of tetracycline use in children under 8 years old?

Permanent tooth discoloration

Which high-risk nutritional practice must be assessed for when a pregnant client is found to be anemic?

Pica

The nurse changed a dressing on a client's wound with vancomycin-resistant enterococci (VRE). Which step would the nurse take to ensure proper disposal of the soiled dressing?

Place the dressing in a red bag/hazardous materials bag.

A newborn is admitted to the neonatal intensive care unit with a myelomeningocele. Which is the priority nursing intervention during the first 24 hours?

Placing the infant in a prone or side-lying position

Which physiological factor increases the risk of falls for a toddler?

Poorly developed depth perception

Two nurses are planning to help a client with one-sided weakness move up in bed. Which principle of body mechanics would the nurses observe?

Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client.

Which type of needs would be placed as an intermediate priority in the prioritization of client care?

Potential needs in care

Which phase of disaster management occurs when the community health nurse in a community that is geographically vulnerable to storms teaches the community about safety measures to be taken during a storm?

Preparedness

Which is the purpose of critical incident stress debriefing (CISD) after a disaster?

Prevent post-traumatic stress disorder (PTSD).

The nurse is caring for a child who has an external fixation device on the leg. Which is the nurse's priority goal when providing pin care?

Preventing infection

Identify the role of plasma cells in the antigen-antibody response.

Produces antibodies against the sensitizing antigen

Which is a primary goal for organized athletics for preadolescent children?

Promotion of teamwork

Which is the nurse's priority responsibility when abuse of an 8-year-old child is suspected?

Protecting the child from future abuse

Which activity would the nurse manager complete during an emergency event when acting as the triage officer according to the Hospital Incident Command System (HICS)? Select all that apply. One, some, or all responses may be correct.

Rapidly evaluating each person who comes to the hospital

To ensure accuracy when assessing a client's blood pressure, how would the nurse prevent a parallax error?

Read the manometer at eye level.

The client with which color tag would be treated first, according to the disaster triage tagging system?

Red

Which action by the nurse would decrease the risk of injury for a child with oppositional defiant disorder?

Redirect anger in other ways

Which goal would be priority for the child with autism spectrum disorder who has frequent episodes of self-biting and head-banging and needs help with feeding and toileting?

Remaining safe from self-inflicted injury

Which action of the emergency department nurse caring for a group of clients injured in a community disaster would need correction?

Removing people from danger

Which initial action would the nurse take when a male toddler with autism spectrum disorder suddenly runs to the wall and starts banging his head on it?

Restrain the toddler to prevent head injury.

Which cereal would the nurse recommend to the parent of an infant who plans to introduce solid foods?

Rice

The nurse is preparing to insert a nasogastric (NG) tube for a client to allow continuous suction. Which tube would the nurse select?

Salem sump

Which agent of terrorism can cause death within a few minutes?

Sarin gas

Which information would the nurse consider when planning care for a client with scabies?

Scabies is highly contagious.

Offspring of men of advanced paternal age are at an increased risk for which condition?

Schizophrenia

An adolescent girl with a seizure disorder refuses to wear a medical alert bracelet. Which would the nurse tell the girl that may help her wear the bracelet consistently?

Select a bracelet similar to bracelets worn by her peers.

Which group of clients who were in a bus accident and admitted to the emergency department with injuries is considered urgent according to the three-tier triage system?

Severe abdominal pain

Which would the nurse do first if an allergic reaction to a blood transfusion occurs?

Shut off the infusion.

A child with meningitis suddenly assumes an opisthotonic position. In which position would the nurse position the child?

Side-lying

Which information would the nurse include in the discharge teaching plan for a client who sustained a cerebrovascular accident (CVA, also known as a "brain attack") with residual hemiparesis and hemianopsia?

Significance of a safe environment

During a period of heavy play activity, a first-grader with a known history of anemia complains of feeling "woozy." Which would be the school nurse's initial response?

Sitting the child on a chair until the dizziness subsides

Which action puts a client at risk for low back injury and pain?

Smoking tobacco

Which should the nurse include when teaching a client with Clostridium difficile about decreasing the risk of transmission to family members?

Soap and water for hand washing

The nurse is assisting a client to transfer from the bed to a chair. Which would the nurse do to widen her or his base of support during the transfer?

Spread his or her feet away from each other

Which stage of the human immunodeficiency virus (HIV) would a client with a CD4+ T cell count of 325 cells/mm3 be classified?

Stage 2

Which precaution would the nurse identify as a prevention for transmission of human immunodeficiency virus (HIV) and other bloodborne illnesses?

Standard

Where is the nurse positioned when performing a Romberg test?

Standing to the side of the client

Which entity would the nurse consult as being ultimately responsible for the implementation of the plan to administer vaccines after an episode of pandemic influenza?

State officials

A client with a terminal illness reaches the stage of acceptance. Which intervention would the nurse use to best assist the client in this stage?

Stay nearby without initiating conversation

Which is the nurse's priority intervention after discovering an infant is apneic?

Stimulate the trunk

Which role does the federal government play in emergency preparedness?

Stockpiles critical equipment

Which strategy would the nurse include in a plan of care for a client with Alzheimer disease?

Structure the environment for safety.

Which factors would the nurse include when discussing adolescent signs of gang membership with parents?

Substance abuse

Which piece of equipment must the nurse ensure remains sterile during care of the client?

Suction catheter

Why is an infection caused by Neisseria gonorrhoeae particularly troublesome for a female client?

Symptoms are often overlooked

When is administration of activated charcoal indicated after a poisoning?

The charcoal has to be administered within 1 hour after the poisoning.

Which risk would the nurse consider when providing care to a client in the acute phase of treatment for a full-thickness burn?

The risk of septicemia and its potential complications from treatment

Which statement is true regarding Community Emergency Response Teams (CERTs)?

They organize untrained volunteers to assist until professional services arrive at the disaster site.

How do toddlers learn self-protection?

Through trial-and-error strategies

Which would the nurse understand to be the role of emergency medical technicians (EMTs) in emergency nursing after a disaster?

To monitor vital signs

The nurse is providing restraint education to a group of nursing students. Which reason to use restraints is incorrect to teach?

To prevent an adult client from getting up at night when there is insufficient staffing on the unit

The client is on neutropenic precautions. From which direction does the protective environment isolation help prevent the spread of infection?

To the client from outside sources

Which issue related to antibiotic use is an increased risk for the older adult?

Toxicity

Which is essential for ensuring disaster readiness in a community?

Trauma system

How often should a health care facility that is Joint Commission accredited plan to test the emergency preparedness plan?

Twice a year

When the nurse is making a home visit to a family with a toddler, which finding indicates a need for education about home safety?

Unlocked cabinets

How would the nurse position a client with epistaxis?

Upright leaning forward

Which intervention is the best approach to condom use for prevention of sexually transmitted infection?

Use of condoms with oral sex

Which risky adolescent behavior has increased in occurrence in recent years?

Using electronic vapor products

Which is the priority nursing action for the nurse caring for a child undergoing chemotherapy to treat leukemia?

Using techniques to minimize risk for infection

Which nursing action is most effective in controlling the spread of infection for an infant with diarrhea?

Washing hands before and after contact with the infant

A client's sputum smears for acid-fast bacilli (AFB) are positive and requires transmission-based airborne precautions. Which instruction would the nurse teach when orienting the client's visitors?

Wear a particulate respirator mask when in the room.

Which strategy is most effective for preventing the transmission of infection?

Wearing gloves and hand hygiene

Which clinical finding would prompt the nurse to withhold an allergy hyposensitization injection?

Wheezing and dyspnea

Which information would the nurse provide a client with diabetes mellitus (DM) regarding alcohol consumption?

With or shortly after meals

Which is the minimum number of disaster drills the hospital disaster plan committee must plan and implement each year?

two