Prep U module 5 - Safety

In developing a security plan for a pediatric unit, a nurse must consider which factors? Select all that apply.

Identification of neonates, infants, toddlers, children, and adolescents at all times The facility's physical layout Available resources to obtain and maintain the security plan Methods for educating all staff regarding the security plan

A client is being discharged from the hospital after being diagnosed with and treated for systemic lupus erythematosus (SLE). What would the nurse not say when teaching the client and family information about managing the disease?

If you have problems with a medication, you may stop it until your next physician visit.

A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated?

IgE

Surgical asepsis is a requirement in the restricted zone of the operating suite. What personal protective equipment should the nurse wear at all times in the restricted zone of the operating room?

Masks covering the nose and mouth

Which of the following is the initial diagnostic in suspected stroke?

Noncontrast computed tomography (CT)

Which court decision or act states that psychotherapists have a duty to exercise reasonable care in protecting the foreseeable victims of their clients' violent actions?

Tarasoff v. Regents of the University of California

The nurse is performing a health history for a 72-year-old client. When reviewing the client's medications, the client states, "I take a baby aspirin every day, but I'm worried. I heard that aspirin can cause hearing problems!" What is an appropriate response by the nurse?

"A baby aspirin is a low dose that is considered to be safe."

Discharge planning is being finalized for a neonate who was born at 32 weeks' gestation and was diagnosed with retinopathy of prematurity. What should the nurse tell the parents?

"An ophthalmologist will examine the baby before discharge."

A nurse is preparing to perform a physical examination on a postpartum client. The client asks the nurse why gloves are necessary for the examination. What is the nurse's best response?

"Gloves are required for standard precautions."

The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention?

"I received a blood transfusion in the United Kingdom."

A client discharged from the hospital 5 days ago following a stroke has come to the emergency department with facial droop that progressed with hemiplegia and aphasia. The client's spouse is extremely upset because the physician stated that the client cannot receive thrombolytic medications to reestablish cerebral circulation and the spouse asks the nurse why. What is the nurse's most accurate response?

"Thrombolytics may cause cerebral hemorrhage."

A health care provider prescribes intravenous normal saline solution to be infused at a rate of 150 ml/hour for a client. How many liter(s) of solution will the client receive during an 8-hour shift? Record your answer using one decimal place (For example: 6.2).

1.2

Your hospital has had an influx of clients who are in respiratory distress and require ventilator assistance. What might this indicate?

A bioterrorism attack

Which client would not be able to undergo a magnetic resonance imaging scan (MRI)?

A client with a pacemaker

What is the main advantage of using a floor stock system?

A nurse can implement medication orders quickly.

A client was found unconscious on the bathroom floor with self-inflicted wrist lacerations. An ambulance was called and the client was transferred to the inpatient psychiatric unit for observation and treatment with antidepressants. Which nursing intervention is most appropriate?

Continue suicide precautions.

A client with lupus has had antineoplastic drugs prescribed. Why would the physician prescribe antineoplastic drugs for an autoimmune disorder?

For their immunosuppressant effects

A nurse is delivering a client's 10 a.m. (1000) medications. The client is away from their room for a diagnostic study. Which action is most appropriate for the nurse to take?

Lock the medications in the medicine cabinet until the client returns.

A nurse is reviewing the dietary history of a client who has experienced anaphylaxis. What would the nurse identify as a common cause of anaphylaxis? Select all that apply.

Milk Eggs Shrimp

While providing education to a young adult during an annual health exam, the nurse discusses health problems common during this stage of development. What is the most common cause of mortality during this stage?

Motor vehicle crashes

The health care provider has prescribed an aminoglycoside (gentamicin) for a client. The nurse is aware that the client is at risk for:

Nephrotoxic acute tubular necrosis

A client admitted with bacterial meningitis must be transported to the radiology department for a repeat computed tomography scan of the head. His level of consciousness is decreased, and he requires 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.

The nurse recognizes which symptom as a clinical manifestation of shock?

Rapid, weak, thready pulse

A client has been prescribed clozapine for schizoaffective disorder (SCA) with depression. The nurse should explain to the client that one advantage of clozapine is that it can provide what?

Reduction of hospitalizations and risk for suicide

After assessing a client, the nurse identifies that the client is at risk for suicide. Which would be the nurse's priority intervention?

Remove means of suicide from the client's access.

Which factors influence safe and effective medication administration for elderly clients?

There is less efficient absorption, detoxification, and elimination.

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.

To ensure patency of central venous line ports, diluted heparin flushes are used

daily when not in use.

A nurse discovers that an I.V. site in a client's hand has infiltrated, causing localized pain and swelling. Which intervention would relieve the client's discomfort most effectively?

elevating the hand and wrapping it in a warm towel

A client with a known cardiac history is being prepared for surgery. Safe use of neuromuscular junction blockers can be best promoted by:

ensuring the client does not take his prescribed amlodipine in the days before surgery.

The nurse is caring for a child with leukemia. Which nursing intervention would be the highest priority for this child?

following guidelines for reverse isolation

A client with epilepsy is having a seizure. During the active seizure phase, the nurse should:

place the client on his side, remove dangerous objects, and protect his head.

A client has been prescribed nasal medication. What care should the nurse take to avoid potential complications due to the administration of this medication?

review the client's medication, allergy, and medical history

The nurse is reconstituting a powdered medication in a vial. After adding the solution to the powder, the nurse should

roll the vial gently between the palms.

With fractures of the femoral neck, the leg is

shortened, adducted, and externally rotated.

The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client:

steps into the walker when walking.

The nurse is working at a local elementary school. A mother arrives to pick up her 6-year-old son and has her 2-year-old daughter in tow. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse?

the 2-year-old leaning against the screen of a window in a classroom

In preparing for a preconception class, the nurse plans to include a discussion of potential risk factors. Which risk factor would be most important to include?

the use of OTC drugs with teratogens

The nurse recognizes which change of the gastrointestinal system is an age-related change?

weakened gag reflex

A client informs the nurse of having taken ibuprofen every 6 hours for 3 weeks to help alleviate the pain of arthritis. The client has a history of a gastric ulcer and is taking a proton pump inhibitor for the treatment of this disorder. What should the nurse instruct the client about the use of the ibuprofen?

"It would be best to contact the health care provider before taking any over-the-counter medications."

After being hospitalized for status asthmaticus, a child is discharged with prednisone and other oral medications. Two weeks later, when the child comes to the clinic for a checkup, the nurse instructs the parent to gradually decrease the dosage of prednisone, which will be discontinued. The parent asks why prednisone must be discontinued. How should the nurse respond?

"Long-term steroid therapy may interfere with a child's growth."

During a private conversation, a client with borderline personality disorder asks a nurse to "keep this secret," then displays multiple, self-inflicted, superficial lacerations of the forearms. What is the nurse's best response?

"The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first."

Which term refers to the inability to coordinate muscle movements, resulting difficulty walking?

Ataxia

What information does a drug label contain? (Select all that apply.)

Brand name of the drug Generic name of the drug Expiration date of the medication Special drug warnings

When assessing a client's I.V. insertion site, a nurse notes normal color and temperature at the site and no swelling. However, the I.V. solutions haven't infused at the ordered rate; the flow rate is slow even with the roller clamp wide open. When the nurse lowers the I.V. fluid bag, no blood returns to the tubing. What should the nurse do first?

Check the tubing for kinks and reposition the client's wrist and elbow.

The OR personnel responsible for maintaining the safety of the client and the surgical environment is the:

Circulating nurse

The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for the unit's clients during a fire alarm?

Close all of the doors on the unit.

A client has a nasogastric (NG) tube. How should the nurse administer oral medication to this client?

Crush the tablets and prepare a liquid form; then insert the liquid into the NG tube.

The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire?

Roll the client in a blanket.

The nurse is providing care for an older adult who has a urinary tract infection. What aspect of this client's current health status should the nurse focus on when ensuring safe and effective antibiotic therapy?

The client has a history of cirrhosis.

A client received chemotherapy 24 hours ago. Which precautions are necessary when caring for the client?

Wear personal protective equipment when handling blood, body fluids, and feces.

A nurse is caring for a client receiving warfarin therapy following a mechanical valve replacement. The nurse completed the client's prothrombin time and International Normalized Ratio (INR) at 7 a.m. (0700), before the morning meal. The client had an INR reading of 4. The nurse's first priority should be to

assess the client for bleeding around the gums or in the stool and notify the physician of the laboratory results and most recent administration of warfarin.

A nurse must provide total parenteral nutrition (TPN) to a client through a triple-lumen central line. To prevent complications of TPN, the nurse should

cover the catheter insertion site with an occlusive dressing.

A client in her first trimester of pregnancy comes to the prenatal clinic and states, "I feel nauseous and I'm vomiting all the time. I can't even keep down water." This client should be evaluated for what condition?

hyperemesis gravidarum

A nurse suspects that a client with a recent fracture has compartment syndrome. Assessment findings may include

inability to perform active movement and pain with passive movement.

After giving birth to an 8-lb (3.6-kg) girl, a client asks the nurse what her daughter should receive for the first feeding. For a bottle-fed neonate, the first feeding usually consists of

iron-fortified infant formula.

An extremely agitated client is brought to the psychiatric unit by the client's partner. The partner reports that the client has been hospitalized several times for treatment of bipolar disorder and has spent thousands of dollars in the past week. The psychiatrist admits the client to the unit for exacerbation of the manic phase of bipolar disorder. Which approach by the nurse promotes a therapeutic relationship with this client?

maintaining a firm but nonthreatening manner

A visiting nurse is teaching a client with heart failure about taking their medications. The client requires six different medications that are taken at four different times per day. The client is confused about when to take each medication. How should the nurse intervene?

Teach a family member to fill a medication compliance aid once per week so the client can independently take their medications.

Which nursing action best addresses the outcome: The client will be free from falls?

Encourage use of grab bars and railings in the bathroom and halls.

The nurse is assisting with the administration of the child's initial dose of parenteral opioids. Which action should the nurse take first?

Ensure naloxone is readily available.

When assessing a client diagnosed with hypochondriasis, the most serious risk factor to be identified for this client is what?

Extensive use of over-the-counter medications

A client has a nursing diagnosis of "ineffective airway clearance" as a result of excessive secretions. An appropriate outcome for this client would be which of the following?

Lungs are clear on auscultation.

The nurse is working with a colleague who has a delayed hypersensitivity (type IV) allergic reaction to latex. Which statement describes the clinical manifestations of this reaction?

Symptoms are localized to the area of exposure, usually the back of the hands.

The nurse is preparing a client for a laser procedure. Which nursing intervention is appropriate?

Apply goggles to the client.

The nurse is caring for a neonate whose mother took benzodiazepines for anxiety during the last 2 months of her pregnancy after a family tragedy. What is the nurse's best action?

Assess for newborn withdrawal syndrome.

A client who underwent abdominal surgery and has a nasogastric (NG) tube in place begins to complain of abdominal pain described as "feeling full and uncomfortable." Which assessment should the nurse perform first?

Assess patency of the NG tube.

The nurse is caring for an ex-soldier who has been diagnosed with posttraumatic stress disorder (PTSD). The nurse should prioritize which action?

Assessing the client for depression and risk for suicide

A registered nurse is staff-shared to the maternal-neonatal unit where the RN has never worked before. How can this nurse be best employed?

Assign the RN a client care assignment in the postpartum unit.

Which motor disorder of sleep can be life threatening?

Obstructive apnea

A home health nurse visits a client who's taking pilocarpine, a miotic agent, to treat glaucoma. The nurse notes that the client's pilocarpine solution is cloudy. What should the nurse do first?

Advise the client to discard the drug because it may have undergone chemical changes or become contaminated.

Accidental removal of one or both parathyroid glands can occur during a thyroidectomy. Which of the following is used to treat tetany?

Calcium gluconate

To obtain information about the chief complaint and medical history of an older client, the nurse asks the client about any medication history. Why is obtaining a medication history important?

It may indicate multiple medications taken by the client.

The nurse is instructing a client who is scheduled for a laryngectomy about methods of laryngeal speech. Which best describes tracheoesophageal puncture (TEP)?

It requires the insertion of a prosthesis into the trachea.

Which is an early sign of Paget disease?

Nipple erythema

A 4-year-old child is scheduled for a nephrectomy to remove a Wilms' tumor. Which intervention listed in the care plan should the nurse question?

Palpate the child's abdomen to monitor tumor growth.

Elderly clients who fall are most at risk for which injuries?

Pelvic fractures

A client has been admitted to the hospital with an exacerbation of peptic ulcer disease. The nurse is aware the client is at risk for:

Perforation Hemorrhage Obstruction

If an indwelling catheter is necessary, which nursing intervention should be implemented to prevent infection?

Perform meticulous perineal care daily with soap and water

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?

Position the client to maintain a patent airway.

An older adult client has newly diagnosed stage 2 hypertension. The health care provider has prescribed Chlorothiazide and Benazepril. What will the nurse monitor this client for?

Postural hypotension and resulting injury

A client receives steroids for several months to treat an inflammatory condition. Which action by the primary health care provider indicates an understanding of the negative feedback mechanism when the client no longer needs the medication?

Prescribing a tapering dose of the medication over weeks

When assessing a client on PCA therapy, the nurse finds the client to be drowsy, with minimal or no response to physical stimulation, scoring a 4 on the Pasero & McCaffery Sedation Scale. What is the nurse's best action?

Stop the medication infusion immediately and notify the primary care provider; prepare to administer oxygen and naloxone.

A care aide has rung the call light for assistance while providing a client's twice-weekly bath because the client became agitated and aggressive while being undressed. Knowing that the client has a diagnosis of dementia of Alzheimer's type and is prone to agitation, which measure may help in preventing this client's agitation?

Reminding the client multiple times that he or she will be soon having a bath

The nurse is screening donors for blood donation. Which client is an acceptable donor for blood?

Reports having a cold 1 month ago that resolved quickly

Which adverse effect(s) should the nurse closely monitor in a client who has secondary immunodeficiencies due to immunosuppressive therapy?

Respiratory or urinary system infections

A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan?

Restrain the baby in a car seat.

A nurse is assigned to care for a recently admitted client who has attempted suicide. What should the nurse do?

Search the client's belongings and room carefully for items that could be used to attempt suicide.

The nurse conducts a home safety assessment for a client. Which statement best explains the standard of care being implemented?

The RN promotes a safe environment.

A client's health care provider has prescribed baclofen in an effort to treat neuropathic cancer pain. What education should the nurse prioritize when teaching the client about this new medication?

The importance of ensuring safety related to possible sedation

Which is defined as the potential of an agent to cause injury to the body?

Toxicity

Which type of ventilator has a preset volume of air to be delivered with each inspiration?

Volume-controlled

During a follow-up visit, a female client who underwent a mastectomy asks the nurse if she can work in her backyard or at least do some household work. Which suggestion would be most appropriate?

Wear gloves and protective clothing to avoid any injuries.