Nurs 208 Exam II

A client on a hospital unit has been infected with hepatitis C virus (HCV) because a nurse mistakenly connected the client with an HCV-positive client's intravenous pump and tubing. What is an appropriate response by the hospital to this incident?

Report this sentinel event to the joint commission and to relevant state agencies

The client is scheduled for a polysomnography to determine if the client has obstructive sleep apnea (OSA). The nurse instructs the client to:

anticipate sleeping overnight at a health care center

The nurse is preparing to discuss safety with a group of parents of infants. When planning the program, which topic would be most important to include?

appropriate positioning in a crib

A client has frequent readmissions for fall-related injuries. Which is the most appropriate intervention by the nurse?

arrange a skilled home care assessment

A nurse assists a patient with ambulation for the first time following a knee replacement. Shortly after beginning to walk, the patient tells the nurse that they are dizzy and feel like they might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient:

- place feet wide apart with one foot in front - rock your pelvis out on the side of the patient - grasp the gait belt - pull the weight of the patient backwards against your body - gently slide the patient down to the floor, protecting their head - stay with the patient and call for help

A nurse working in a long-term care facility uses proper principles of ergonomics when moving and transferring patients to avoid back injury. Which action should be the focus of these preventative measures?

carefully assessing the patient care environment

A nurse is applying restraints to a confused client who has threatened the safety of a roommate. Which actions would the nurse perform when properly applying restraints to a client? Select all that apply.

- Check agency policy for the application of restraints and secure a health care provider's order. - Pad bony prominences. - Remove the restraint at least every 2 hours or according to agency policy and client need.

A nurse is providing active-assistive range-of-motion exercises for a patient who is recovering from a stroke. During the session, the patient reports that they are "too tired to go on." What actions are appropriate at this time? Select all that apply.

- stop performing the exercises - reevaluate the plan of care - assess the patient for additional symptoms of intolerance

A nurse works in a facility stating they support a culture of safety. What will the nurse expect to find operationalized in this culture? Select all that apply.

- support for reporting errors and near misses without blame - commitment of resources to address actual/potential safety issues - promotion of teamwork and collaboration throughout the organization - administrators and managers commitment to safe operations

A nurse is developing an exercise program for a patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply.

- teach the patient to avoid sudden position changes that may cause dizziness - tell the patient to avoid exercising in very cold or very hot temperatures

A nurse caring for patients in a pediatric office assesses children's achievement of developmental milestones. Which patient finding requires follow-up with the pediatrician?

6 month old infant who is unable to hold head up

A group of nursing students is learning about the body's response to stress. Which system is responsible for initiating the fight-or-flight response to stress?

Sympathetic nervous system

A nurse hears a client yelling for help from the room. Upon arriving the nurse notes tachypnea and a sense of panic. On further evaluation, the client's heart rate is increased as well as oxygen needs. Which step would the nurse take first to address this client's needs?

attempt to calm the client and administer oxygen

A nurse smells smoke and subsequently discovers a fire in a garbage can in a common area on the hospital unit. What is the nurse's priority action in this situation?

rescue anyone who is in immediate danger

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement requires immediate nursing intervention?

"only certain members of the health care team can extinguish fires"

A nurse is getting a patient with right hemiparesis out of bed to the chair. What will the nurse say to the patient?

"the chair is by your non-affected leg for smoother movement"

A nurse failed to document the administration of a client's warfarin and the nurse on the next shift administered the drug again, believing that it had been overlooked. When performing root cause analysis, what question should be asked first?

"what could the two nurses have done to ensure this did not happen?"

A nurse is using the Katz Index of Independence in Activities of Daily Living (ADLs) to assess the mobility of a hospitalized patient. During the patient interview, the nurse documents the following patient data: "Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self." Based on this data, which score would the patient receive on the Katz index?

4

A new parent inquires about the use of a car seat for their infant. Which information provided by the nurse is most accurate regarding the use of a rear-facing safety seat for an infant?

A rear facing safety seat should be used for infants and toddlers younger than 2 years old or up to the maximum weight for the seat.

A nurse is caring for an acutely confused hospital client who is ordered to remain on bed rest for medical reasons. The nurse asks the health care provider for an order for restraints. Which guidelines for the use of restraints should the nurse follow? Select all that apply.

- the clients family must be involved in the decision and care plan - alternatives to restraints and les restrictive interventions must have been implemented and failed - the benefit gained from the restraint must outweigh the known risks for that client

The nurse would like to promote ventilation in a client with chronic obstructive pulmonary disease by elevating the client's arms. What intervention should the nurse implement?

place a small pillow under each arm

A nurse on a medical-surgical unit notes a patient with pneumonia and is experiencing dyspnea. What action will the nurse take to improve the dyspnea?

place the patient in the fowlers position

The nurse is delegating inactive client positioning to a UAP. What directions will the nurse include?

placing the client in good alignment with joints slightly flexed

A nursing student asks the primary nurse why an immobile patient developed two urinary tract infections (UTIs) in the 6 months. How does the nurse best explain this patient's risk for UTI?

urinary stasis

A client with difficulty sleeping is prescribed ramelteon. The client asks the nurse, "How does this medicine work?" Which information would the nurse include in the response?

Activates the receptors for the hormone melatonin

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which initial intervention is appropriate?

Assess for the need to urinate

A client has been in the hospital for the past 10 days following the development of an infection at her surgical incision site. Each morning, the client reports overwhelming fatigue and has told the nurse, "I just can't manage to get any sleep around here." How should the nurse first respond to this client's statement?

Assess the factors that the client believes contribute to the problem

The nurse is caring for a school-age child and notices a variety of circular burns on the back and legs in various stages of healing. What action should the nurse take related to this suspicion?

Notify the national abuse hotline

An experienced nurse and new graduate nurse are caring for a confused older adult who gets out of bed and wanders. The preceptor intervenes when observing which action by the graduate nurse?

Raising all four side rails to keep the patient in bed

The nurse wishes to keep a client from sliding down toward the foot of the bed. Into which position will the nurse place the client?

Slight trendelenburg

The nurse makes the following assessment. A middle-age client reports falling asleep frequently at his job during the day, feels like he is not getting enough sleep at night (even though the number of hours of sleep is unchanged), continues to feel tired, and is not able to think clearly. Also, the client reports his wife believes he is irritable upon awakening. Nursing interventions include teaching the client to:

Use caution when driving an automobile

A nurse is reviewing the medication administration record. Which order does the nurse question?

a diuretic administered twice daily at 9am and 9pm

Many families are sheltering in the local middle school gymnasium during a severe tornado outbreak. Many homes have been destroyed and lives lost. The community health nurse expects to see negative stress reactions to the crisis, such as:

a young wide asking everyone repeatedly if they know where her husband is

The nurse and an unlicensed assistive personnel (UAP) are transferring a client from a bed onto a stretcher. Prior to the move, where should the nurse position the stretcher?

along side the bed at the same height

The nurse is completing an admission assessment for a client scheduled for back surgery after a construction accident. The nurse notes the client is having slowed speech and focus, irritability, yawning, and that he reports severe lumbar and right leg pain. The nurse suspects which primary nursing concern?

altered sleep pattern related to acute pain

A nurse in a long-term care facility is on an interprofessional safety committee focusing on protecting older adults from injury and trauma. Which action does the nurse suggest they prioritize?

maintaining clutter free rooms and hallways

While discussing home safety with the nurse, a patient admits that they smoke a cigarette in bed before falling asleep at night. Which health problem is the priority for this patient?

nonadherence: etiology, nonadherence to recommendation to stop smoking

The nurse is teaching the caregiver of an adolescent child about safety. Which teaching will the nurse include?

peer pressure causes children of this age to take risks

A nurse is caring for a patient with lower extremity paralysis. Which action will the nurse take to prevent external rotation of the hip and foot?

use a trochanter roll

A patient has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient?

keep elbows close to the sides of the body

A nurse working in a pediatrician's office receives calls from parents whose children have ingested a toxic substance from under the sink. How will the nurse advise the parents?

Call the PCC immediately before attempting any home remedy

The nurse manager is assessing the unit for proper work ergonomics. Which finding will require immediate intervention by the nurse manager?

Equipment is positioned to the side, 50 degrees away

A nurse in a psychiatric care unit finds that a client with psychosis has become violent and is actively trying to harm another client in the unit. What action should the nurse take?

call for assistance to remove the client from the area

A client is brought to the emergency department after inhaling a substance suspected to be anthrax from the contents of an envelope. What symptoms experienced by the client would the nurse correlate with this substance?

cough, dyspnea, and fatigue

The nurse is assisting with client transfer. Which guideline(s) will the nurse consider prior to helping the client move from the bed to a chair? Select all that apply.

- Lower the bed to the lowest position allowing the client's soles to contact the floor. - Provide the client with nonskid slippers to put on prior to standing up. - Provide step-by-step instructions to the client before the transfer begins.

A young woman, who has recently suffered acute stress, asks the nurse why she seems to be more sensitive to stress than her husband. The nurse explains that a contributor to this phenomenon is:

estrogen levels

Which Knowledge, Skills, and Attitudes (KSAs) are nursing actions based on the QSEN competency of quality improvement? Select all that apply.

- The nurse manager schedules a meeting of staff to review client outcomes on the hospital ward. - The nurse schedules a meeting with the nurse manager to review and update the policies for client admissions. - The nurse administrator sets up a committee to review the procedure manual and recommend any needed changes.

A nurse is making a home visit for a client with several home safety concerns. On which safety concept(s) would the nurse advise the client? Select all that apply.

- remove extension cords from open spaces - check the batteries in all smoke detectors - ensure appropriate lighting in hallways and entrances - remove throw rugs from high traffic areas

The client is a clerical assistant for an inpatient hospital unit. He spends most of his day at a desk. What would the nurse advise the clerical assistant to do to minimize damage to his musculoskeletal system? Select all that apply.

- adjust the height of the work area - face in the direction of the activity he is performing - use a wide stance and lift with the large leg muscles

A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. Which instructions from the nurse are appropriate for this patient? Select all that apply.

- breathe in and out smoothly during quadricep setting exercises - place the bed in the lowest position or use a foot stool for dangling - perform quadriceps two to three times per hour, for to six times a day

A school nurse is teaching about adolescent safety with students entering high school. What will the nurse include in the discussion about the major causes of death in this group? Select all that apply.

- car accidents - suicide

The nurse is caring for a client who has been placed in physical restraints. Which nursing action is appropriate? Select all that apply.

- communicate with the family regarding the need for restraints - check circulation and skin condition frequently and regularly - offer opportunities for toileting frequently and regularly

The nurse is able to help promote safety and prevent injury by identifying which factors that have a direct impact on client safety? Select all that apply.

- communication ability - developmental level - mobility

The nurse manager and nurses in an acute care hospital are participating in a safety huddle to identify patients at risk for falling. Which patients will the nurses determine require follow-up? Select all that apply.

- history of falling - presence of postural hypotension - transferred from long term care

A school nurse is teaching parents about home and fire safety. What information will be included in the teaching plan? Select all that apply.

- most people who die in fires die of smoke inhalation - fire related injury and death have declined due to availability and use of smoke alarms - fires are more likely to occur in homes without electricity or gas

The nurse is caring for a client that is disoriented. The nurse places the client in soft wrist restraints to discourage pulling at a nasogastric tube. Which nursing action(s) is appropriate? Select all that apply.

- obtain order from a licensed provider within minutes of application - check circulation and skin condition every 2 hours - offer regular, frequent opportunities for toileting

A client reports to the nurse, "Sleep really isn't necessary." Which teaching by the nurse is appropriate? Select all that apply.

- sleep helps your blood flow to the brain - sleep helps you to learn easier and remember more - sleep helps your immune system fight off infections

A nurse is instructing a patient recovering from a stroke on proper use of a cane. What information will the nurse include in the teaching plan?

support weight on the stronger leg and cane and advance weaker foot forward

The client is contracting their leg muscles as part of rehabilitation. When the muscles contract, which element is released into the client's sarcoplasmic reticulum?

calcium

A nurse is teaching parents in a parenting class about the use of car seats and restraints for infants and children. What should be the focus of this education?

booster seats should be used for children until they are 4'9" tall and weigh between 80-100lbs

During the admission process, a nurse orients an older adult to their hospital room. What is the current safety priority?

demonstrating how to operate the call bell

The nurse is assessing the gait of an older adult who is walking with knees slightly flexed and body leaning slightly forward. Which is the nurse's best action?

document a common gait for the older adult

Nursing students are invited to participate in the clinical agency's annual disaster drill, simulating the release of an airborne infectious agent and ensuing panic. Which assignment is most appropriate for the students?

ensuring everyone entering and working has an N95 mask

Which statement should the nurse include in the education plan regarding safety issues for a group of adult clients?

in most age groups, motor vehicle accidents are major causes of death

As a part of his workout regimen, a 21-year-old college football player often engages in squats and lateral arm holds. These are examples of what type of exercise?

isometric

A nurse is assisting a patient who is 2 days postoperative from a cesarean section dangle in preparation for sitting in a chair. After assisting the patient to stand up, the patient's knees buckle and she tells the nurse she feels faint. What is the appropriate nursing action?

lowering the patient back to the side of the bed and pivoting her back into bed

A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for the patient tells the AP not to place the patient in which position?

prone

A nurse is completing an intake assessment. The nurse notes that an older adult client appears to have bruises in varying stages of healing. Which is the nurse's most appropriate initial action?

question the client about the source of the bruises

A nurse is filing a safety event report for a confused patient who fell while getting out of bed. Which action is most appropriate during documentation?

recording the circumstances and effect on the patient in the health record

An older adult client has developed diabetic neuropathy. What would be the most important safety education intervention for the client and family?

reduce the temperature of the water heater

A nurse is assessing a client who was exposed to botulism from contaminated food supplies. Which symptom would the nurse expect to find in this client?

skeletal muscle paralysis that progresses symmetrically and in a descending manner

The nurse is assessing an older adult client who is having difficulty with mobility. Assessment reveals that the client has stiff and awkward muscle movements. The nurse identifies this as:

spasticity

The nurse begins a shift and finds that the wrong medication has been administered to a client. After completing a safety event report, what should the nurse do next?

submit the safety report to the appropriate department within the facility so that it can be reviewed

The pediatric nurse teaches parents about normal sleep patterns in their children. Which education point should the nurse include?

Inform parents that daytime napping decreases during the preschool period, and by the age of 5 years, most children no longer nap

A nurse applies padded boots to maintain the unconscious client's foot in dorsiflexion. The nurse is protecting the client from what complication?

Foot drop

The nurse is providing education for parents on the four month-old infant's sleep patterns. Which education will the nurse provide?

The infant should generally sleep 12-16 hours per day

A client is experiencing a stress response each time the family visits the room. What nursing intervention is most appropriate?

limit the family visits to once daily

A community health nurse is providing education on child safety. Who does the nurse identify as at highest risk for choking and suffocation?

an infant sleeping in the prone position

A nurse is caring for a patient who is on bedrest following a spinal injury. Which action is appropriate to prevent foot drop

ask the family to bring in high-top sneakers to maintain foot dorsiflexion

The nurse has delegated several parts of basic care for a client who is a fall risk to an unlicensed assistive personnel (UAP) member. Which UAP action requires nursing intervention?

assisting the client to put on slippers prior to ambulation

The nurse directs the unlicensed assistive personnel (UAP) to assist an inactive client with positioning. Which action by the UAP would cause the nurse to intervene?

lowering the height of the bed prior to moving the client

A nurse is instructing new parents on the proper sleeping position for their newborn. In what position does the nurse instruct the parents to place the newborn?

supine position

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail to prevent this behavior, and chemical restraints fail, which treatment does the nurse anticipate will be ordered?

temporary application of devices that reduce the clients ability to move arms

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure?

Extremity restraint

The nurse is assessing a client who has presented at the ambulatory care unit. The nurse notes the client has impaired muscle coordination. The nurse documents the presence of what health problem?

ataxia

The hospital's fire alarm sounds, and an announcement is made that there is a fire in a patient room. What is the priority for nurses on the unit?

removing all patients from the room or vicinity

For the last 3 weeks, a nurse in a long-term care facility has administered a sedative hypnotic to a client who complains of insomnia. The client does not seem to be responding to the drug and is now lying awake at night. What is the most likely explanation?

most sedatives hypnotics lose their effect after 1 or 2 weeks of administration

A nurse has exhausted every effort to keep a confused, postoperative patient safe and in bed. Following The Joint Commission guidelines for use of restraints, which nursing action reflects safe practice?

ensuring that two fingers can be inserted between the restraint and the patient's wrist

Two nurses are repositioning a patient and pulling the patient up in bed. Which of these steps is most appropriate to prevent injury to the nurses?

ensuring the bed is at the level of the nurses hips

The nurse is educating health care providers on implementation of a hospital disaster plan. What consideration should the nurse prioritize?

establish the nurses role during a disaster

Which behaviors represent effective coping mechanisms? Select all that apply.

- setting limits with family members who upset you - learning relaxation techniques - taking a vacation

Which of the nurse's interventions best addresses the leading cause of death in the United States?

Heart health education

A disoriented older resident likes to wander the halls of their long-term care facility but becomes agitated when they cannot find their room. Which action is most appropriate as an alternative to restraints?

Identifying their door with his photograph and a balloon

Two nurses will transfer an older adult client from her bed to a chair later in the day. How can the nurses best facilitate a successful transfer?

If the client is in pain, administer analgesics in advance of the transfer

The nurse is performing a physical assessment on an adolescent. What assessment priorities are needed for this age group?

scoliosis

The nurse has identified the nursing concern of injury risk due to the use of assistive mobility devices in an unfamiliar environment. What outcome is most appropriate for this client's care plan?

the client will demonstrate safety measurements to prevent falls

The acute care nurse is caring for a client who is at risk for falling. Which desired outcome is most appropriate for this client?

the client will not experience a fall and remains free of injury

The home care nurse observes that a child has recently learned to ride a bicycle and is now riding independently. Which would the nurse teach the child about bicycle safety?

the importance of being visible at night

A toilet trained toddler was admitted to the hospital for dehydration. Upon returning home, the toddler becomes incontinent of urine and stool. The parent is concerned regarding this return to previous behavior and calls the pediatric clinic. What is the nurse's best response to the parent?

this behavior is called regression

Which actions should the nurse perform to help prevent occupational safety hazards? Select all that apply.

- use equipment only for the use for which it was intended - Only operate equipment the nurse is familiar with - Use three-pronged electric plugs whenever possible