NU 302 Safety and Infection Control Question Set 1

While changing bed linens the nurse notices a metal object on the bottom sheet of a client with radiation seeds implanted in the bladder. Which action should the nurse take? Select all that apply.

-Walk away from the item. -Notify the radiation department.

A client is on a stretcher and needs to be transported to another location. Which action should the nurse take to prevent a personal injury when transporting this client?

Stand at the head of the stretcher and push the device.

The parent of a school-age client with diabetes tells the nurse that she does not want the school to know about her daughter's condition. Which is the nurse's best response?

"What is it that concerns you about having the school know about your daughter's condition?"

An infant received the wrong medication dose. What is the charge nurse's role in following up on the incident?

Objectively assess the circumstances surrounding the error.

Which situations should a supervisor consider in making assignments for nurses in the neonatal unit?

A pregnant nurse shouldn't care for a neonate with cytomegalovirus (CMV).

A nurse is supervising a new graduate registered nurse who is caring for a client hospitalized with active tuberculosis (TB). Which action by the new graduate requires the nurse to intervene?

A surgical face mask is applied before entering the client's room.

The unlicensed assistive personnel (UAP) records a capillary blood glucose of 253 mg/dL (14.04 mmol/L) and the nurse administered insulin for coverage to the client. The UAP reports to the nurse that the blood glucose was incorrect. What actions should the nurse take? Select all that apply.

A. Obtain a current blood glucose level. B. Observe the client for hypoglycemia. C. Report the incident to the healthcare provider. D. Complete an incident report.

A toddler taking penicillin for acute otitis media developed a maculopapular rash 24 hours ago after 3 days of therapy. The parents report no other abnormal symptoms. The nurse takes what initial action?

Assess chest sounds and oxygen saturation.

The nurse is admitting a 4-year old with a possible meningococcal infection. Which type of isolation is indicated?

droplet precautions EXPLANATION: Meningococcal infections are spread through close mucous membrane or respiratory contact with large respiratory droplets. Meningococcal infections are not spread by small airborne organisms or contact with a person's skin or contaminated items. Standard precautions, used when touching body fluids, are not sufficient to prevent the spread of meningitis.

A primiparous client who gave birth vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining nearby the client to assess for which problem?

fainting

An adolescent receiving care is inadvertently injured with a warm compress. The nurse completes an incident report, knowing the report's goal is to:

record facts surrounding each incident.

Indicate on the illustration where the nurse would place the other electrode of the automated external defibrillator on a victim who has collapsed and does not have a pulse.

(PICTURE) One electrode is placed to the right of the upper sternum just below the right clavicle. The other is placed, as shown, over the fifth or sixth intercostal space at the left anterior axillary line.

An infection control nurse is reviewing the care of a client diagnosed with Clostridium difficile infection. The nurse determines that the staff is adhering to appropriate infection control precautions based on implementation of which measure?

contact precautions

The nurse has done fall prevention teaching with the family of a client who is being discharged home. Which action by the client and family indicates that the teaching has been effective?

eliminating home safety hazards

The nurse on the oncology unit is caring for a client with a total white blood cell (WBC) count equal to 2000/µL (2.0 ×109/L). Which intervention is most important to include in the plan of care?

perform proper hand hygiene

A parent of a 9-year-old-child scheduled to have surgery expresses concern about the potential for postoperative infection. A nurse provides the parent with information about the measures taken to maintain surgical asepsis. Typical surgical asepsis involves:

performing a preoperative surgical scrub for at least 3 to 5 minutes.

A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan?

placing the client in respiratory isolation

Which of the following objects poses the most serious safety threat to a 2-year-old client in the hospital?

side rails in the halfway position

The nurse is planning care for a client with severe postoperative pain. There is a prescription for morphine written as "10 mg MSO4" on the medical record. What should the nurse do first?

Contact the health care provider (HCP) who prescribed the medication.

The nurse is to apply a sequential compression device (intermittent pneumatic compression). Identify the area of the compression device that is placed on the client's calf.

PICTURE The air cell should be centered on the back of the client's calf.

The nurse is caring for a client with Clostridium difficile infection. Prior to entering the room, which step would the nurse take?

Put on a gown

A nurse is working on a labor and delivery unit that requires all visitors to pass a screening protocol prior to entry. What is the nurse's priority action when a person gains access to the unit after bypassing the screening protocol?

Stop the visitor, and ask for identification.

A nurse realizes she is 1 hour and 30 minutes late in administering a dose of medication for a 4-year-old child. She gives the medication immediately, and assesses the child. The child isn't harmed by the delay. Which action should the nurse take next?

The nurse should follow facility procedures for reporting an error.

The nurse is taking care of a client with neutropenia. Which nursing action is most important in preventing cross-contamination?

changing gloves immediately after use

When developing the plan of care for a client with suicidal ideation, the nurse should address which priority issue?

safety

When planning care for a client who has ingested phencyclidine (PCP), the nurse's highest priority should be meeting the client's:

safety needs

Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education?

"The client is receiving physical therapy twice per day, so they don't need a continuous passive motion device."

A nurse-manager is auditing the nursing unit's adherence to infection-control practices. Which observation causes the nurse-manager to be most concerned that the clients on the unit are at risk for infection?

A nurse does not wear a gown when caring for a client on contact precautions.

A client has soft wrist restraints to prevent the client from pulling out the nasogastric tube. Which nursing intervention should be implemented while the restraints are on the client?

Check on the client every 30 minutes while the restraints are on.

An alarm signals, indicating that a neonate's security identification band requires attention. The nurse responds immediately and finds that the parents removed the identification bands from the neonate. Which action should the nurse take next?

Compare the information on the neonate's identification bands with that of the mother's, then reattach the identification bands to one of the neonate's extremities.

The nurse is admitting a client with glaucoma. The client brings prescribed eye drops from home and insists on using them in the hospital. What should the nurse do?

Explain to the client that the health care provider (HCP) will write a prescription for the eye drops to be used at the hospital.

A parent calls the health clinic and tells the nurse that the toddler was found with an open and empty bottle of acetaminophen. The parent asks the nurse what to do. What is the nurse's priority intervention?

Give the parent instructions on how to call poison control.

The nurse is planning care with an older adult who is at risk for falling because of postural hypotension. Which intervention will be most effective in preventing falls in this client?

Instruct the client to sit, obtain balance, dangle legs, and rise slowly.

The nurse has answered the telephone at the nurses' station, and the individual on the line states that there is bomb in the healthcare facility. What is the nurse's best response?

Keep the individual on the line in order to gather more information about the details of the threat.

The nurse observes a family member of a client who is on contact precautions enter and exit the client's room without performing hand hygiene. What is the nurse's most appropriate action?

Offer to show family members how to perform hand hygiene using soap and water or hand sanitizer.

What should the nurse do to ensure safety for a hospitalized blind client?

Orient the client to the room environment.

An infant requires cardiorespiratory monitoring. A nurse must locate and clean the necessary equipment, move it into the infant's room, and secure it to the bedside wall-mounting device. Which principles should a nurse use to complete this task safely?

Principles of infection control and ergonomics

A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. The client's level of consciousness is decreased, and they require nasopharyngeal suctioning before transport. Which infection control measures are best when caring for this client?

Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport.

Which nursing intervention is appropriate for a client with an arm restraint?

monitoring circulatory status every 2 hours

A parent tells the nurse that their 6-year-old child has severe nosebleeds. To manage the nosebleed, the nurse should tell the parent to:

place the child in a sitting position with the neck bent forward and apply firm pressure on the nasal septum.

A school-age client is admitted to the facility with a diagnosis of acute lymphocytic leukemia (ALL). The nurse formulates a nursing diagnosis of Risk for infection. What is the most effective way for the nurse to reduce the client's risk of infection?

practicing thorough hand washing

A nurse reports to the hospital occupational health nurse (OHN) that the nurse was splashed with blood during the resuscitation of an HIV-positive client. The nurse asks the OHN when test results will show positive or negative for HIV infection for the nurse. Which is the most appropriate response by the OHN?

"Accurate results will be obtained by testing at 3 months and again at 6 months."

The risk for injury during an attack of Ménière's disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo?

"Assume a reclining or flat position."

The nurse is teaching a group of new parents about car seat safety. The nurse would know education has been effective when a parent makes which statement?

"I can use a front-facing car seat when my baby reaches the size limit of the rear-facing seat."

The nurse is discharging a baby with clubfoot who has had a cast applied. The nurse should provide additional teaching to the parents if they make which statement?

"I should use a pillow to elevate my child's foot as he sleeps."

A client who has been sexually assaulted is admitted to the emergency department (ED). Which is the most important initial statement by the nurse?

"I'll stay with you while you're here."

A nurse is conducting a teaching session with a group of parents on infant care and safety to assist parents in appropriately preparing to take their neonates home. Which statement about automobile restraints made by one of the parents would indicate to the nurse that learning has taken place?

"Infants should ride in a rear-facing car seat until they have reached the maximum weight allowed by the car seat manufacturer or are 2 years old." EXPLANATION: The American Academy of Pediatrics recommends that infants should ride in a rear-facing car seat until they have reached the maximum weight or height allowed by the car seat manufacturer or until they are at least 2 years old.

An obese client has returned to the unit after receiving electroconvulsive therapy (ECT). A nurse requests assistance in moving the client from the stretcher to the bed. Which direction should the nurse give to a nurse who volunteers to help?

"Obtain the sliding board or two other people to assist us." EXPLANATION: To successfully move an obese client from the stretcher to the bed without incurring injury, at least four staff members must perform the transfer. If only two people are available, the nurse should use the sliding board. The hydraulic lift isn't the appropriate equipment to use with a sedated patient. The nurse shouldn't place the client in a semi-Fowler's position unless there is a head injury or other complicated medical condition. To perform a safe transfer using a drawsheet, the nurse must place the sheet directly under the client's body.

A client in early labor is connected to an external fetal monitor. The physician hasn't noted any restrictions on her chart. The client tells the nurse that she needs to go to the bathroom frequently and that her partner can help her. How should the nurse respond?

"Please press the call button. I'll disconnect you from the monitor so you can get out of bed."

After teaching the parents of a 15-month-old child who has undergone cleft palate repair how to use elbow restraints, which statement by the parents indicates effective teaching?

"We'll remove the restraints temporarily, one at a time, at least three times a day to check his skin, then put them right back on."

A child who tests positive for the human immunodeficiency virus (HIV) is placed in foster care. The foster parents ask the nurse how to prevent HIV transmission to other family members. How should the nurse respond?

"Wear gloves when you're likely to come into contact with the child's blood or body fluids."

The parent of a school-age client with diabetes tells the nurse that she does not want the school to know about her daughter's condition. Which is the nurse's best response?

"What is it that concerns you about having the school know about your daughter's condition?" EXPLANATION: The nurse's first response should be to obtain more information about the mother's concerns. The nurse can then facilitate a dialogue that will help the mother weigh her concerns against the potential risks to the child's safety. It is true that the nurse would not discuss a client's medical condition with a school without permission, but this statement does facilitate discussion. It is also true that the child may have a diabetic reaction anywhere at school, and it is advisable that her teacher, classmates, and other adults know about her diabetes in order to help her; however, it is ultimately the client and her parents who will make the decision about informing the school. Dictating to the mother does not explain any rationale for the necessity of sharing the information.

The student nurse is caring for a client who has an order for 2 units of packed red blood cells. The nurse educator asks the student, "Prior to the administration of blood, another nurse must do what?" What would be the most appropriate responses from the student? Select all that apply.

-"Check the blood." -"Check the healthcare provider's order." -"Check the ABO compatibility."

The nurse finds a small fire in the linen closet. Which action(s) should the nurse take to minimize the consequences of the fire? Select all that apply.

-Contain the fire. -Rescue clients who are at risk. -Activate the alarm. -Use a fire extinguisher.

What should the nurse do to prevent catheter-associated urinary tract infection? Select all that apply.

-Provide perineal care at least once a day. -Maintain a closed drainage system. -Encourage the client to drink 3,000 mL of fluids a day.

What clinical manifestations would the nurse expect to see in an 18-month-old experiencing anaphylaxis? Select all that apply.

-lip edema -hives -rhinorrhea EXPLANATION: Clinical manifestations of anaphylaxis include hypotension, lip edema, hives, rhinorrhea, and an aura of doom. However, an 18-month-old could not express an aura of doom so, therefore, it would not be expected as an assessment.

A child with a body surface area (BSA) of 0.82 m2 has been prescribed actinomycin 2.5 mg/m2 intravenously. What is the correct amount to be given? Record your answer using two decimal places.

2.05

A client who is bedridden has slid down in the bed. Which principle of body mechanics should the nurse use when repositioning the client? Select all that apply.

A. Align self to prevent personal injury. B. Prepare the client to be in normal anatomical alignment. C. Keep the client in anatomical alignment during the move. D. Use large muscle groups to prevent sore muscles and joints.

When developing a teaching plan for parents of toddlers about poisonous substances, the nurse should emphasize which safety points? Select all that apply.

A. Toddlers should be adequately supervised at all times. B. All poisonous substances should be kept out of the reach of children and stored in a locked cabinet if necessary. C. The difference between pediatric and adult dosages of medicines is significant, and adult dosages given to children can have serious, harmful effects. D. Following any poisoning, the parents should call the Poison Control Center for instructions for appropriate treatment.

The nurse meets with a client in the outpatient clinic who is suicidal and refuses participate in creating a suicide safety plan. What should the nurse do next?

Arrange for immediate hospitalization on a locked unit.

The nurse develops a teaching plan for the client about how to prevent the transmission of hepatitis A. Which discharge instruction is appropriate for the client?

Ask family members to wash their hands frequently. EXPLANATION: The hepatitis A virus is transmitted via the fecal-oral route. It spreads through contaminated hands, water, and food, especially shellfish growing in contaminated water. Certain animal handlers are at risk for hepatitis A, particularly those handling primates. Frequent handwashing is probably the single most important preventive action. Insects do not transmit hepatitis A. Family members do not need to stay away from the client with hepatitis. It is not necessary to disinfect food and clothing.

A staff nurse receives a phone call and is told there is a bomb in a client's room. What is the nurse's priority action?

Ask the caller for details about the bomb placement.

A client with stage II Alzheimer's disease is admitted to the short stay unit after cardiac catheterization that involved a femoral puncture. The client is reminded to keep their leg straight. A knee immobilizer is applied, but the client repeatedly attempts to remove it. The nurse is responsible for three other clients who underwent cardiac catheterization. What's the best step the nurse can take?

Ask the staffing coordinator to assign a nursing assistant to sit with the client.

Several large boxes of supplies need to be relocated to another room on a client care area. Which action should be taken to prevent the staff from experiencing back injuries when moving these supplies?

Break the boxes into smaller and lighter loads.

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

Check the equipment.

A cloth chest restraint has been prescribed for a client who is restless and combative due to alcohol intoxication. What is an appropriate nursing intervention for this client?

Check the extremities for circulation based on hospital protocols.

A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad?

Client's level of consciousness

A nurse assesses a client with psychotic symptoms and determines that the client likely poses a safety threat and needs vest restraints. The client is adamantly opposed to this. What would be the best nursing action?

Contact the physician and obtain necessary orders.

A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa, throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary importance?

Demonstrating control over aggressive behavior

Four clients in a critical care unit have been diagnosed with Pseudomonas aeruginosa. The Infection Prevention and Control Department has determined that this is probably a nosocomial infection. What should the nurse do to prevent spread of the disease?

Ensure that staff members do not have artificial fingernails. EXPLANATION: It is well documented that the subungual areas of the hand harbor bacteria that can be transmitted to others despite aggressive handwashing procedures, and therefore, it is important that the staff on this unit do not have artificial fingernails that could be the source of the infection on this unit. There is no need to institute transmission-based or contact precautions. It is not necessary to wear a mask when caring for these clients.

A nurse is transferring a client from the bed to a chair. Which action should the nurse take during this client transfer?

Help the client dangle his legs.

A nurse is documenting a variance that has occurred during the shift, and this report will be used for quality improvement to identify high-risk patterns and potentially initiate in-service programs. This is an example of which type of report?

Incident report.

A client is admitted to the emergency department with a closed head injury after being found unconscious. Based on information from the client's neighbor, the staff suspects intimate partner violence. The client has a restraining order against the spouse, but the spouse repeatedly attempts to visit the client. Which action should the nurse take?

Inform hospital security personnel of the restraining order and description of spouse.

A client from a correctional facility is admitted to the hospital wearing handcuffs. The nurse caring for the client needs to provide morning care and notices the two correctional officers socializing with the nursing staff at the desk. What is the best action by the nurse in this situation?

Insist that the officers stay in the room at all times.

The nurse is caring for a 5-year-old child with a femur fracture. The parent explains that the fracture occurred from a fall. The child's recollection of the event conflicts with the parent's explanation. What is the nurse's immediate responsibility?

Keep the child safe, and assess for abuse.

A mother of a 5-year-old child who was admitted to the hospital has a Protection from Abuse order for the child against his father. A copy of the order is kept on the pediatric medical surgical unit where the child is being treated. The order prohibits the father from having any contact with the child. One night, the father approaches the nurse at the nurses' station, politely but insistently demanding to see his child, and refusing to leave until he does so. What should the nurse do first?

Notify hospital security or the local authorities. EXPLANATION: The Protection from Abuse order legally prohibits the father from seeing the child. In this situation, the nurse should notify hospital security or the local authorities of this attempt to breach the order, and allow them to escort the father out of the building. The father could be jailed or fined if he violates the order. The nurse shouldn't argue or continue explaining to the father that he must leave because it could place the nurse and the child at risk if the father becomes angry or agitated. The nursing coordinator and nurse-manager should be notified of the incident; the nurse's first priority, however, should be contacting security or the authorities.

A client returns to the nursing division after a procedure under general anesthesia. The client reports being awake during the procedure and recalls certain events. What is the nurse's priority intervention?

Notify the anesthesia practitioner.

While making rounds, the nurse finds a client with chronic obstructive pulmonary disease sitting in a wheelchair, slumped over a lunch tray. After determining the client is unresponsive and calling for help, what should the nurse do next?

Open the client's airway.

Which instruction should a nurse include in a home-safety teaching plan for a pregnant client?

Place a nonskid mat on the floor of the tub or shower.

A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement?

Related to impaired balance

An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. What should the nurse advise the mother to do?

Remove any unsafe items from the area in which the infant is mobile.

A nurse enters a client's room and finds a pillowcase on fire where it was placed over a table lamp. Which action should the nurse perform first?

Remove the client from the room.

While reviewing the day's charts, a nurse who's been under a great deal of personal stress realizes that the nurse forgot to administer insulin to client with diabetes mellitus. The nurse has made numerous errors in the past few weeks and is now afraid this job is in jeopardy. What is the best course of action?

Report the error, complete the proper paperwork, and meet with the unit manager. EXPLANATION: Making an error can be very stressful and a nurse may feel great pressure to hide the mistake or not follow protocol. Discussing the problem with the unit coordinator may help the nurse address some of the underlying stress that led up to making the error. Nonetheless, the nurse must still report the error and complete the proper paperwork. The nurse should contact the physician and follow their instructions, but shouldn't bypass proper protocol.

A nurse in a psychiatric care unit finds that a client with psychosis has become violent and has struck another client in the unit. What action should the nurse take in this case?

Restrain the client, as they are harmful to the other clients. EXPLANATION: The nurse should restrain the client because they are potentially harmful to other clients in the psychiatric care unit. Restraints should be used as a last resort and their use should be justified. Unnecessary restraining can lead to allegations of false imprisonment and battery; both are not applicable in this case, however. The nurse should inform the physician about the client but sometimes it may not be logical to wait for orders to restrain a violent client.

The nurse administers an antipsychotic drug to a client with acute mania. The client still refuses to lie down on her bed, pushes other clients in the hallways, and screams threatening remarks to the staff. What should the nurse do next?

Seclude the client and use restraints if necessary. EXPLANATION: The client is visibly out of control, and other measures have not helped. Therefore, the nurse needs to seclude the client and use restraints if necessary to protect the client and others from harm. Following the client and asking her to calm down or telling the client to lie down on the sofa is not helpful because the client's level of anxiety is too high for her to attempt to calm down on her own and she cannot control her behavior. Telling the staff to ignore the client's remarks is not helpful because the client needs external means of control to protect the client, other clients on the unit, and the staff. Safety is the priority.

The client in balanced suspension traction is transported to surgery for closed reduction and internal fixation of a fractured femur. What should the nurse do when transporting the client to the operating room?

Send the client on the bed with extra help to stabilize the traction.

The nursing student is having difficulty obtaining a mobile computer for the purpose of administering medications using the electronic medical record. The student has been reprimanded for delivering medications late in the past and wants to ensure timely administration. What action should the student take?

Speak to the instructor about the unavailability of mobile computers for medication administration, and request assistance in obtaining one.

The nurse is planning to move a box of dialysis solution in a client's room. Which action should the nurse take to reduce the risk of a back injury?

Stand close to the box.

When assessing a hospitalized client diagnosed with major depression and borderline personality disorder, the nurse should ask the client about which of the following first?

Suicidal thoughts.

A group of people arrives at the emergency department reporting extreme periorbital swelling, cough, shortness of breath, and tightness in the throat. They report that someone threw a bomb that exploded at their feet. What is the best action by the nurse?

Take them to the decontamination area.

A client has an indwelling urinary catheter and is prescribed physical therapy. As the client is being placed in a wheelchair, which action by the assistant would need further clarification by the nurse?

The catheter bag is placed on the client's lap for safe transport.

A client is scheduled for a computed tomography (CT) of the chest with contrast media. Which finding should the nurse report immediately to the healthcare provider?

The client has hypersensitivity to iodine.

A psychiatric treatment team is planning care for a client who was involuntarily admitted for treatment of depression and suicide ideation. When planning the client's care, what legal parameters of care should the nurse be aware of?

The client is able to refuse medications. EXPLANATION: Competent clients have the right to refuse medications. A client is considered competent unless the court has declared that the client is incompetent. Even though the client is an involuntary admission, nothing in the scenario indicates the client is not competent and thus able to be involved in treatment planning. Because the client was admitted involuntarily, the client is not able to obtain release. A guardian or representative who is responsible for giving consent is appointed by the court for a client who has been determined to be incompetent.

The nurse-manager of a 20-bed coronary care unit is not on duty when a staff nurse makes a serious medication error that results in a client's overdose. The client nearly dies. Which statement accurately reflects the accountability of the nurse-manager?

The nurse-manager would receive a call at home from the on-duty nursing supervisor, apprising the nurse-manager of the problem as soon as possible.

An older adult alert and oriented client is admitted to the hospital for treatment of cellulitis of the left shoulder. Which fall prevention strategy is most appropriate for this client?

Use a night-light in the bathroom.

After the spouse has visited, a client begins crying and saying that the spouse is a mean person. When the client starts pounding on the overbed table and using incomprehensible language, the nurse feels incapable of handling the situation. What should the nurse do at this time?

Use the call system to request assistance.

A client who is homeless is admitted for treatment of a severe infection. The client reports, "I'm allergic to everything." The nurse reviews the client's medical records at that facility and learns that the client has extensive identified medication allergies. What is the best action for the nurse to take?

Use the drug allergy listing in the medical record as a starting point for a full allergy assessment.

An adolescent client is having surgery to repair a fractured left femur. As a part of the preoperative safety checklist, what should the nurse do?

Verify that the site, side, and level are marked.

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?

a client with a nasogastric tube EXPLANATION: Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.

In the emergency department, a client with facial lacerations states that the spouse beat the client with a shoe. After the lacerations are repaired, the client waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence the spouse represents. Suddenly the client's spouse arrives, shouting a desire to "finish the job." What is the first priority of the nurse who witnesses this scene?

calling a security guard and another staff member for assistance

In the emergency department, a client with facial lacerations states that the spouse beat the client with a shoe. After the lacerations are repaired, the client waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence the spouse represents. Suddenly the client's spouse arrives, shouting a desire to "finish the job." What is the first priority of the nurse who witnesses this scene?

calling a security guard and another staff member for assistance EXPLANATION: The nurse who witnesses this scene must take precautions to ensure personal as well as client safety, but shouldn't attempt to manage a physically aggressive person alone. Therefore, the first priority is to call a security guard and another staff member. After doing this, nurse should inform the spouse what is expected, speaking in concise statements and maintaining a firm but calm demeanor. This approach makes it clear that the nurse is in control and may defuse the situation until the security guard arrives. Telling the spouse to leave would probably be ineffective in the agitated and irrational state. Exploring the spouse's anger doesn't take precedence over safeguarding the client and staff.

A client is 4 days postoperative from a tibia fracture and has a long leg cast. The nurse is conducting initial teaching for walking with crutches. What is the most important activity for the nurse to encourage the client to do prior to discharge from the hospital?

conduct exercises in bed to strengthen the upper extremities, as this will assist the client in crutch use. EXPLANATION: When walking with crutches, the client engages the triceps, trapezius, and latissimus muscles. A client who has been immobilized may need to implement an exercise program to strengthen these shoulder and upper arm muscles before initiating crutch walking. The other choices are incorrect based on functionality and muscle use.

A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require?

contact

A client is admitted to the acute psychiatric care unit after 2 weeks of increasingly erratic behavior. The client is unkempt, has lost approximately 9 lb (4 kg), has been sleeping poorly, and exhibits hyperactivity. The client loudly denies the need for hospitalization. What priority intervention will the nurse apply?

decreasing environmental stimulation

The nurse is admitting a 4-year old with a possible meningococcal infection. Which type of isolation is indicated?

droplet precautions

A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is to:

ensure safety by initiating suicide precautions. EXPLANATION: The nurse's first priority is to keep a suicidal client safe and alive. Although establishing a rapport and promoting trust are important in psychiatric nursing, neither is the highest priority. Using restraints is inappropriate and could be interpreted as punishment of the client or a convenience for the nurse. Trying to communicate in writing is also inappropriate because there is no indication that the client can't hear.

A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature?

every 15 minutes EXPLANATION: In order to prevent burns, the nurse should assess the client's temperature every 15 minutes when using an external warming device.

A neonate is experiencing respiratory distress and is using a neonatal oxygen mask. An unlicensed assistive personnel has positioned the oxygen mask as shown. The nurse is assessing the neonate and determines that the mask:

is appropriate EXPLANATION: The mask is appropriate because it covers the nose and mouth and fits snugly against the cheeks and chin. The mask is not too low. Masks that are too large may cover the eyes. Masks that are too small obstruct the nose.

A nurse is caring for a client with a history of falls. The nurse's first priority when caring for a client at risk for falls is

keeping the bed in the lowest possible position.

A parent tells the nurse that the parent's preschool-aged child with spina bifida sneezes and gets a rash when playing with brightly colored balloons, and that recently the child had an allergic reaction after eating kiwi fruit and bananas. Based on the parent's report, the nurse suspects that the child may have an allergy to

latex

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

manual resuscitation bag EXPLANATION: The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.

A client has a coxsackie B (viral) or trypanosomal (parasite) infection. The nurse should further assess the client for which health problem?

myocarditis

A client is admitted to the healthcare facility with active tuberculosis (TB). The nurse should include which intervention in the care plan?

putting on an individually fitted mask when entering the client's room EXPLANATION: Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a mask when entering the client's room. Occupational Safety and Health Administration (OSHA/Canadian Centre for Occupational Health and Safety) standards require an individually fitted mask. Having the client wear a mask at all times would hinder sputum expectoration and respirations would make the mask moist. A nurse who does not anticipate contact with the client's blood or body fluids need not wear a gown or gloves when providing direct care. A client with TB should be in a room with laminar airflow, and the room's door should be closed at all times.

A nurse is assigned to a client with a cardiac disorder. The nurse should question an order to monitor the client's body temperature by which route?

rectal

A client refuses the evening dose of haloperidol and then becomes extremely agitated in the day room while other clients are watching television. The client begins cursing and throwing furniture. The nurse's first action is to:

remove all other clients from the day room.

When planning care for a client who has ingested phencyclidine (PCP), the nurse's highest priority should be meeting the client's:

safety needs. EXPLANATION: The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as those of the staff. Drug effects are unpredictable and prolonged, and the client may easily become aggressive and physically violent. After safety needs have been met, the client's physical, psychosocial, and medical needs may be addressed.

A client has moved into the acquired immunodeficiency syndrome (AIDS) phase of the human immunodeficiency virus (HIV) positive infection. The nurse advises the client to avoid what outdoor recreational activity?

swimming in rivers or lakes

Which activity should the nurse recommend to the client on an inpatient unit when thoughts of suicide occur?

talking with the nurse EXPLANATION: Talking with a staff member when suicidal thoughts occur is an important part of contracting for safety. The nurse or another staff member can then assess whether the client will act on the thoughts and assist the client with methods of coping when suicidal ideation occurs. Writing in a journal, engaging in physical activity, or playing games with others does not allow the client to verbalize suicidal thoughts to the nurse.

A nurse is teaching parents how to reduce the spread of impetigo. The nurse should encourage parents to:

teach children the importance of proper hand washing.

The nurse is placing a client with severe neutropenia in reverse isolation. What should the nurse tell the client why this is necessary? Reverse isolation helps prevent the spread of organisms:

to the client from sources outside the client's environment.

The nurse administers a medication by the intramuscular route to a client. Which action would put the nurse most at risk for a needlestick injury?

using one-handed needle recapping immediately after administration

A nurse is supervising a new nurse who is preparing to perform wound care for a client whose abdominal wound is infected with vancomycin-resistant enterococci. The supervising nurse should make sure that the new nurse:

wears a gown and gloves while caring for the client.

The mother of a client who has a radium implant asks why so many nurses are involved in her daughter's care. She states, "The doctor said I can be in the room for up to 2 hours each day, but the nurses say they are restricted to being here for 30 minutes." What should the nurse explain to the client?

work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation.

A nurse recognizes that a client with tuberculosis needs further teaching when the client states:

"It will be necessary for the people I work with to take medication."

The client has a latex allergy. What should the nurse teach the client to do before having surgery? Select all that apply.

-Determine that there will be a latex-safe environment for surgery. -Report symptoms experienced with the latex allergy (e.g., rhinitis, conjunctivitis, flushing). -Notify the health care providers (HCPs) at the surgery center.

The unlicensed assistive personnel (UAP) records a capillary blood glucose of 253 mg/dL (14.04 mmol/L) and the nurse administered insulin for coverage to the client. The UAP reports to the nurse that the blood glucose was incorrect. What actions should the nurse take? Select all that apply.

-Obtain a current blood glucose level. -Observe the client for hypoglycemia. -Report the incident to the healthcare provider. -Complete an incident report.

The nurse received an order to administer intravenous fluids with potassium for a client receiving intravenous fluids. What step(s) are included in the process? Select all that apply.

-Review the client's laboratory values. -Obtain correct ordered intravenous fluids. -Identify client with two methods. -Review the label of the intravenous tubing.

A client moves in with her family after her boyfriend of 4 weeks told her to leave. She is admitted to the subacute unit after reporting feeling empty and lonely, being unable to sleep, and eating very little for the last week. Her arms are scarred from frequent self-mutilation. What should the nurse do in order of priority from first to last? All options must be used.

A. Monitor for suicide and self-mutilation. B. Monitor sleeping and eating behaviors. C. Discuss the issues of loneliness and emptiness. D. Discuss her housing options for after discharge. EXPLANATION: Safety is the priority concern, and then eating and sleeping patterns need to be reestablished. After intervening to meet basic needs, delving into the loneliness and emptiness are important for determining underlying issues that need to be followed up in outpatient counseling. Although the client is living with her family currently, other options might be appropriate for her to consider.

The nurse is caring for an immune-compromised client with a fungal infection of the scalp. What recommendation should the nurse make to prevent future problems?

Avoid sharing combs and brushes.

A nurse preparing to discharge a child with leukemia observes a family member who has a cold sharing a meal with the child. How should the nurse approach the situation?

Offer a face mask to the person with the cold and use this as an opportunity for further teaching. EXPLANATION: Offering a face mask is the best approach; it protects the child while supporting the family and using the situation as an opportunity for learning. Instructing family members that it isn't healthful to share food and to avoid the child if they're sick are technically correct, but these responses don't include a rationale that enables the family to understand why these actions are important. The nurse should have posted an isolation sign on the child's door long before the time of the child's discharge.

Before assisting a client to ambulate after surgery, the nurse helps the client to dangle the feet over the side of the bed. Which action will best prepare the client to dangle the feet over the side of the bed?

Place the client in a high Fowler's position.

A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then

advance both crutches.

Which action is the best precaution against transmission of infection?

eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection

The nurse is instructing a client with cancer who is receiving chemotherapy about reporting signs of infection. Which is the most reliable early indicator of infection in a client who is neutropenic?

fever

A toddler receiving chemotherapy after surgery for a Wilms' tumor has developed neutropenia. The parent is trying to encourage the child to eat by bringing extra foods to the room. Which food would the nurse discourage for this child?

fresh strawberries

A client with cervical cancer is undergoing internal radium implant therapy. A lead-lined container and a pair of long forceps have been placed in the client's hospital room. What should the nurse tell the client about how these will be used? The forceps and container will be used for:

handling of the dislodged radiation source.

The children of an elderly client who has suffered an ischemic stroke have informed the nurse that an herbalist will be coming to their parent's bedside tomorrow to make recommendations for client's care. Which considerations should the nurse prioritize in light of the practitioner's planned visit?

ensuring any complementary therapies are safe when combined with his prescribed therapy

The nurse is administering oxycodone for leg pain, as requested by the client. What priority actions will the nurse implement? Select all that apply.

-Verify the healthcare provider's order. -Assess the client for allergies. -Assess the client's respirations. -Identify the client. EXPLANATION: The nurse will verify the order, assess for allergies, and identify the client for safe medication administration. The nurse needs to assess the client's respiratory system because oxycodone can cause respiratory depression. The nurse does not have to assess the client's activity level for the pain medication administration.

A nurse is verifying a medication calculation completed by a nursing student prior to administration. The adult client is to receive ampicillin 150 mg/kg/day I.V. divided in 6 even doses with a maximum dose of 12 g/day. The client's weight is 80 kg. How many mg/dose will the client receive? Record your answer using whole number.

2000

The nurse is caring for a client in the newborn nursery. What appropriate actions can the nurse take that will help to prevent neonatal infection? Select all that apply.

A. good hand washing technique B. isolation of infected infants with communicable disease C. hand sanitizer with points of contact EXPLANATION: For population health measures, hand washing and using hand sanitizer remain the most important infection control procedure for contact with all newborns. The caregiver should wash their hands before and after each newborn contact. Isolation of infected infants also prevents the spread of infection. A separate gown technique is not necessary in most situations unless the infant is infectious and has a communicable disease. Covering the umbilical cord with sterile gauze is also unnecessary to prevent infection in the infant.

The night nurse has completed the change of shift report. As the day nurse makes rounds on a postpartum client receiving magnesium sulfate, it is noted the client developed significantly elevated blood pressure during the past shift. Further assessment reveals the magnesium sulfate rate is infusing well below the prescribed rate. In addition to adjusting the infusion rate and notifying the health care provider (HCP), what is the most important action by the nurse?

Complete an incident report. EXPLANATION: Safety is the highest priority, and a nursing error has occurred. If the day nurse decides to tell the night nurse, the timing of the notification will be up to the nurse initiating the incident report. The nurse should confer with the charge nurse concerning the incident, but completion of the report is required. Waiting for several hours to initiate the report based on changes in client data and assessment is not an ethical or professional decision and should not be considered; again, safety is the highest priority.

Which nursing intervention is most important in preventing septic shock?

maintaining asepsis of indwelling urinary catheters

The client is being directly admitted from a healthcare provider's office to the hospital with abnormal laboratory results. Which healthcare providers will need to use two identifiers with the hospital admission process? Select all that apply.

-the admission secretary applying the name band -the admission nurse obtaining a health history EXPLANATION: The healthcare providers that need to use two identifiers are the admission secretary applying the name band and the admission nurse obtaining a health history. The other healthcare workers, unit secretary arranging further diagnostic studies, hospital chaplain visiting the clients on the unit, and the housekeeper completing the room cleaning, are not working directly with the client during the hospital admission.