Safety and infection control

A nurse finds that a fire has broken out in a client's room at the health care facility. Which intervention is of the highest priority? Extinguish the fire. Rescue the client. Raise an alarm. Confine the fire.

Rescue the client. The first priority in case of fire is to rescue the client. As per the RACE principle of fire management, the rescue of the client is the first step, followed by raising an alarm, confining the fire, and finally, extinguishing the fire.

When changing a sterile surgical dressing, a nurse first must wash her hands. put on sterile gloves. remove the old dressing while wearing clean gloves. open sterile packages and moisten the dressings with sterile saline solution.

wash her hands.

Which nursing instructions help parents of a child with hemophilia provide a safe home environment for their child? "Pad the corners of coffee tables when your child is a toddler and provide kneepads for sports when the child is older." "Establish a written emergency plan including what to do in specific situations and the names and phone numbers of emergency contacts." "Be a role model to your child by wearing a helmet when riding a bike so your child will, too." "Talk with your child about home safety and have him problem-solve hypothetical situations about his health."

"Establish a written emergency plan including what to do in specific situations and the names and phone numbers of emergency contacts."

The nurse is caring for three clients who have been diagnosed with anthrax. They were exposed after boarding a flight where a white powdery substance was found in one of the restrooms. The nurse knows that these clients would be classed as being victims of which of the following? A biologic disaster A natural disaster A radiologic disaster A chemical disaster

A biologic disaster

A client is discharged to his daughter's home. He weighs 250 lb (113.4 kg) and is immobile. The nurse should instruct the daughter on the use of a: three-person lift. transfer with a gait belt. A client is discharged to his daughter's home. He weighs 250 lb (113.4 kg) and is immobile. The nurse should instruct the daughter on the use of a: three-person lift. transfer with a gait belt. hydraulic lift. stand-up assist lift. stand-up assist lift.

A client is discharged to his daughter's home. He weighs 250 lb (113.4 kg) and is immobile. The nurse should instruct the daughter on the use of a: three-person lift. transfer with a gait belt. hydraulic lift. stand-up assist lift.

Which is an example of an unintentional tort? Nurses discuss a client's laboratory values in the elevator. A nurse tells a client that the client cannot leave the hospital until the client pays the bill. A nurse threatens to restrain a client if the client does not stop talking. A nurse gives the client a medication, and the client has an adverse reaction to it.

A nurse gives the client a medication, and the client has an adverse reaction to it.

A client develops an infection with a resistant organism while hospitalized for surgery. After treatment, there are no obvious signs of infection, but a culture shows that the organism is present. Which term describes the client's status? Chronic disease Preclinical stage Clinical disease Carrier status

Carrier status

Sexually transmitted infections (STIs) are typically spread by which mechanisms? Penetration Vertical transmission Direct contact Ingestion

Direct contact

A client diagnosed with influenza is admitted to the hospital. Which transmission-based precautions should the nurse initiate? Droplet Airborne Contact Neutropenic

Droplet

A nurse is caring for a female client following a motor vehicle accident resulting in paraplegia. The client is ready for discharge to home with her husband, who states, "I'm scared to carry her because I'm afraid I'll either hurt my back or drop her." What information will the nurse give the husband during discharge teaching? Ergonomic principles and body mechanics The importance of monitoring urinary elimination Nutritional changes for the client with paraplegia Signs and symptoms of chronic back pain that should be reported to the health care provider

Ergonomic principles and body mechanics

Which piece of personal protective equipment (PPE) should be removed first? Gloves Respirator Gown Goggles

Gloves

Which scenario is an example of how international travel has contributed to increased prevalence and incidence of nonindigenous diseases? An airline pilot getting ill after eating pork in a restaurant in Hong Kong Outbreak of hemolytic-uremic syndrome related to contaminated salad being shipped to various regions Increase in the number of reported Lyme disease cases related to a hot summer with local large deer population Hepatitis A outbreak when a restaurant worker forgot to wash the hands after using the restroom

Outbreak of hemolytic-uremic syndrome related to contaminated salad being shipped to various regions

Which organism is responsible for Rocky Mountain spotted fever? Rickettsia Bacillus Protozoan Chlamydiaceae

Rickettsia

A 10-year-old child presents to the emergency department with dehydration. A physician orders 1 L of normal saline solution be administered at a rate of 60 ml/hour. While preparing the infusion, a nurse notices that the I.V. pump's safety inspection sticker has expired. Which action should the nurse take next? After starting the fluids, contact the maintenance department and request a pump inspection. Hang the fluids without the pump, carefully calculating the drip rate by visual inspection. Take the pump out of commission and locate a pump with a valid inspection sticker. Begin the infusion of the fluids while looking for a pump with a valid inspection sticker.

Take the pump out of commission and locate a pump with a valid inspection sticker.

After demonstrating to a group of nursing students the proper technique for handwashing using soap and water, the nursing instructor determines that the teaching has been successful when the students demonstrate which of the following? Washing the hands for 5 to 10 seconds Vigorously scrubbing between the fingers Removing the soap with a paper towel before rinsing Washing underneath artificial fingernails

Vigorously scrubbing between the fingers

Which term refers to the tendency for a chemical to become a vapor? Persistence Volatility Toxicity Latency

Volatility

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. Place the object on the bedside table. Place the object on the sink in the bathroom. Scoop the item with a tissue and place in the trash.

Walk away from the item. Notify the radiation department.

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 legs. advance the unaffected leg. advance the affected leg. advance both crutches.

advance both crutches.

The nurse is instructing the family on home care of a client with shingles. The family member asks whether their teenage children should stay in a different room. What is the best response by the nurse? "Yes, shingles is highly contagious." "Have they had chickenpox or the varicella vaccine?" "No, shingles is not contagious." "Because the client is in quite a bit of pain, it would probably be best."

"Have they had chickenpox or the varicella vaccine?"

A patient with a fractured left fibula is being taught how to use crutches. Which statement by the patient indicates that the teaching was effective? "I should make sure my underarms are supported by the tops of the crutches." "I need to allow my arms and hands to support my body weight." "I need to position the crutches even with my heels when standing." "I need to learn to use one type of gait for getting around."

"I need to allow my arms and hands to support my body weight."

A nurse is teaching a client about allergic rhinitis. What client statements indicate teaching has been effective? Select all that apply. "I should use my medication for allergy exacerbation only when my allergy is apparent." "I am allowed to miss only one desensitization appointment before my treatment is affected." "I can only have one alcoholic drink while I am taking my antihistamine." "I need to reduce my exposure to people that have upper respiratory infections." "I will remove as much carpet from my house as I can."

"I need to reduce my exposure to people that have upper respiratory infections." "I will remove as much carpet from my house as I can."

The nurse is teaching the client who has an immunodeficiency disorder how to avoid infection at home. Which statement indicates that additional teaching is needed? "I will wash my hands whenever I get home from work." "I will make sure to have my own toothbrush and tube of toothpaste at home." "I will avoid contact with people who are sick or who have recently been vaccinated." "I will be sure to eat lots of fresh fruits and vegetables every day."

"I will be sure to eat lots of fresh fruits and vegetables every day."

Which client has an absolute neutrophil count (ANC) that is critically low and the standard of care would recommend placement on neutropenic precautions? Client on long-term steroids for rheumatoid arthritis with WBC of 7000/µL (7 x 109/L). 37-year-old client with leukemia being treated with chemotherapy with ANC of 400 (0.40 x 109/L). 65-year-old client with prostate cancer receiving radiation therapy with neutrophil count of 2,000/μL (2.0 x 109/L). 75-year-old client with renal failure receiving Epogen for anemia with hemoglobin level of 9.7 g/dL (97 g/L).

37-year-old client with leukemia being treated with chemotherapy with ANC of 400 (0.40 x 109/L).

Which information is essential for a nurse to include in the teaching plan for a client receiving metronidazole for trichomoniasis? Do not take food with this medication. Do not drink grapefruit juice while on this medication. Abstinence is recommended until the therapy is completed. After taking the medication, sit upright for half an hour.

Abstinence is recommended until the therapy is completed.

A nurse is caring for a client with a fresh postoperative wound following a femoral-popliteal revascularization procedure. The nurse fails to routinely assess the pedal pulses on the affected leg, and missed the warning sign that the blood vessel was becoming occluded. The nurse manager is made aware of the complication and the nurse's failure to assess the client properly. What action should be taken by the nurse manager? Review the nurse's malpractice insurance policy. Address the nurse's omissions as negligent behavior. Ask the nurse whether the client refused the assessments. Reprimand the nurse for being forgetful.

Address the nurse's omissions as negligent behavior.

When do most perinatal HIV infections occur? Through breastfeeding In utero After exposure during delivery Through casual contact

After exposure during delivery

Which scenario is the best example of a nurse attending an in-service program? Attending a hospital program on how to use a new IV pump Attending a continuing education program given by a national organization Attending a conference on cultural diversity Taking an online course at a local university

Attending a hospital program on how to use a new IV pump

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. Wash hair with a dandruff-preventing shampoo. Keep hair length short and well trimmed. Allow hair to air dry after shampooing.

Avoid sharing combs and brushes.

Which method is reliable for identifying a preschooler before administering a medication? Check the name on the bed. Check the hospital identification bracelet. Ask the child his name. Ask the parents at the bedside.

Check the hospital identification bracelet.

A school nurse is conducting a seminar for parents of preschool children on the prevention of head injuries. What is the most appropriate information for the nurse to give the parents? Children should always be supervised by an adult when playing. Safety gates should be installed at staircases at home. Children should always wear helmets when riding bicycles. Children should be accompanied by an adult when crossing the street.

Children should always wear helmets when riding bicycles.

A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented? Circulating nurse Scrub nurse Surgeon Registered nurse first assistant

Circulating nurse

Which type of law protects each person's freedom and property rights? Criminal law Statutory law Civil law Administrative law

Civil law

Which client should the nurse determine is at greatest risk for vancomycin-resistant enterococci (VRE) infection? Client receiving chemotherapy Client who had leg surgery Client on a short course of vancomycin Client in the ICU for one day

Client receiving chemotherapy

A client is diagnosed with scabies in a long-term care facility. Which type of client care precautions would the nurse institute? Strict Contact Respiratory Enteric

Contact

A client who has experienced the recent loss of an infant child and recent immigration to the United States is admitted to the inpatient psychiatric unit with severe symptoms of depression. The client has expressed thoughts of suicide. Which is the nurse's priority intervention for this client? Exploring the grief and loss issues concerning the baby's death. Encouraging the client to express feelings of isolation following the recent immigration. Encouraging attendance at group cognitive-behavioral therapy on the unit. Ensuring that the client is not permitted to use anything that would be potentially dangerous.

Ensuring that the client is not permitted to use anything that would be potentially dangerous.

Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora? Escherichia coli in the intestinal tract Escherichia coli in the urinary tract Shigella in the intestinal tract Shigella in the urinary tract

Escherichia coli in the intestinal tract

A public health nurse is presenting an educational event to the local disaster response team on radiation injury. The nurse describes a client whose burns and trauma are evident. What type of radiation injury is this? External Direct Internal Indirect

External

A nurse is administering evening medications and notices that a medication was omitted during the day shift. Which statement demonstrates the principle of accountability? Administering the medication with the other evening medications Telling the client that the medication will be given the following morning Filling out an occurrence report and notifying the healthcare provider Documenting in the chart a narrative note about the occurrence

Filling out an occurrence report and notifying the healthcare provider

In an allergic reaction, the immunoglobulin that binds to mast cells that release histamine is the: IgE. IgA. IgG. IdD.

IgE.

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. Nurse's shift report. Transfer report. Telemedicine report.

Incident report.

A parent informs the nurse that their family was on vacation, staying in a hotel, and woke up to the sound of a knock at the door. When they opened the door, their 8-year-old child was standing at the door not knowing where he was. This was not the first occurrence of sleepwalking for this child. Which objective should be the priority concern? Finding the cause of the sleepwalking Injury during an episode of sleepwalking Type of medication allergy the child has How many episodes a week the child is having

Injury during an episode of sleepwalking

In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that the nurse has made. The nurse is most clearly demonstrating which professional value? Integrity Altruism Social justice Human dignity

Integrity

The nurse is in the radiology unit of the hospital. The nurse is caring for a client who is scheduled for a lung scan. The nurse knows that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for? Bleeding Iodine allergy Dysrhythmias Inflammation

Iodine allergy

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? Gown Masks covering the nose and mouth Goggles Gloves

Masks covering the nose and mouth

During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has which type of injury? Life-threatening but survivable with minimal intervention Minor; treatment can be delayed hours to days Significant; injuries require medical care but can wait hours without threat to life or limb Extensive; chances of survival are unlikely even with definitive care

Minor; treatment can be delayed hours to days

A family member is caring for an older adult client with osteomalacia in the home. When the home health nurse comes to evaluate the client, what should be a focus point of the visit? Making sure the client is receiving a daily bath Ensuring that the client is eating enough Observing for safety hazards that could be a fall risk Making sure the client has adequate financial resources

Observing for safety hazards that could be a fall risk

What initial measure can the nurse implement to reduce risk of injury for a client with liver disease? Pad the side rails on the bed Apply soft wrist restraints Raise all four side rails on the bed Prevent visitors, so as not to agitate the client

Pad the side rails on the bed

A 12-year-old is being hospitalized for pneumonia. The nurse receives the client's culture and sensitivity report on her tracheal aspirate. The client is infected with a strain of Streptococcus pneumoniae, which is particularly prone to cause infections, also referred to as what? Virulent Pathogenic Specific Source

Pathogenic

Homeland Security has alerted the disaster response teams in your region of a potential terrorist attack in the form of a nuclear blast. You are a part of the disaster response system and you know that with a nuclear blast you would need to be prepared for what classification of disaster? Radiologic Chemical Biologic Manmade

Radiologic

What should the nurse include in the teaching plan for a client with allergies to help control symptoms? Select all that apply. Remove dusty items from the environment. Wear a dampened mask if dust or mold is a problem. Avoid smoke-filled rooms. Avoid extreme temperatures, like when in air-conditioned areas. Notify the health care provider at the first sign of allergy symptoms.

Remove dusty items from the environment. Wear a dampened mask if dust or mold is a problem. Avoid smoke-filled rooms.

Following an education session on proper hand hygiene, the nurse educator observes a nurse washing hands before entering a client's room. Which observation would alert the nurse educator to the need for further education? The nurse dries from finger tips down toward elbows. The nurse dries from forearms up toward fingers. The nurse keeps hands lower than elbows while washing. The nurse uses at least 3 to 5 mL of liquid soap.

The nurse dries from forearms up toward fingers.

Using proper body mechanics, which motions would the nurse make to move an object? The nurse balances the head over the shoulders, leans forward, and relaxes the stomach muscles when moving an object. The nurse uses the muscles of the back to help provide the power needed in strenuous activities. The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. The nurse directly lifts an object rather than sliding, rolling, pushing, or pulling it, thus reducing the energy needed to lift the weight against the pull of gravity.

The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.

Levels A, B, and C are levels assigned to potential agents of bioterrorism. What are these categorical assignments based on? Safety to terrorist Transmissibility Environmental impact Ease of use to terrorist

Transmissibility

The nurse has completed an intervention with a client. There is no visible soiling on the nurse's hands. Which technique is recommended by infection control practice standards for hand hygiene? Decontaminate hands using an alcohol-based hand rub. Do not wash hands; apply clean gloves. Wash hands with soap and hot water. Wash hands with soap and water, followed by an alcohol-based hand rub.

Wash hands with soap and water, followed by an alcohol-based hand rub.

The nurse empties a Jackson-Pratt drainage bulb. Which nursing action ensures correct functioning of the drain? irrigating it with normal saline connecting it to low intermittent suction compressing it and then plugging it to establish suction connecting it to a drainage bag and clamping it off

compressing it and then plugging it to establish suction

The nurse should inform a young female client that the barrier method providing the best protection against sexually transmitted infections (STIs) is: condoms. a diaphragm. a cervical cap. spermicides.

condoms.

An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which measures should the nursing staff prioritize in preventing the spread of MRSA to clients who are currently MRSA-negative? diligent handwashing practices reduced length of stay for MRSA-positive clients constant use of gloves when on the unit prophylactic antibiotic therapy for MRSA-negative clients

diligent handwashing practices

Which action is the best precaution against transmission of infection? eye prophylaxis with antibiotics for a neonate whose mother has hepatitis B infection strict isolation for a neonate whose mother has cytomegalovirus (CMV) infection eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection strict isolation for a neonate whose mother has human immunodeficiency virus (HIV)

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? 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 chills tachycardia dyspnea

fever

A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action? remove the garments that are most contaminated make contact between two contaminated surfaces make contact between two clean surfaces handwashing before leaving the client's room

handwashing before leaving the client's room

During flu season, a nurse is teaching clients about the chain of infection. What components are considered "links" in this chain? Select all that apply. virulence infectious agent portal of entry susceptible host fomites

infectious agent portal of entry susceptible host

A nurse has collected the blood, urine, and stool specimens of a client with meningococcal meningitis. Which precaution should the nurse take when transporting the specimens? wear gloves and a gown when transporting the specimen place each of the three sealed specimens in a separate paper bag place the specimens into plastic biohazard bags swab the outside of each specimen container with alcohol prior to transport

place the specimens into plastic biohazard bags

The nurse has begun the intravenous infusion of the first dose of a client's prescribed antibiotic. A few minutes later, the client is diaphoretic, gasping for breath and has a heart rate of 145 beats per minute. After calling for help, what is the nurse's priority action? protecting and maintaining the patency of the client's airway monitoring the client's vital signs at least every five minutes administering intravenous antihistamines as prescribed providing reassurance to the client

protecting and maintaining the patency of the client's airway

A new nurse is asked to start an I.V. on an antepartum client. The new nurse has performed the procedure only once and isn't familiar with the I.V. pumps used in this facility. The new nurse should: ask another new nurse to assist her. attempt the procedure without assistance. review the unit's procedure manual. tell the client that she isn't experienced enough to start the I.V.

review the unit's procedure manual.

A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection? surgical asepsis increased T cells decreased antibiotics increased vitamin C

surgical asepsis

Which is not appropriate regarding the use of gowns as PPE? use of paper or cloth gowns donning a gown when splashing use of one gown per person per shift use of a new gown each time the nurse enters the room

use of one gown per person per shift

The nurse understands that the purpose of the "time out" is to: verify all necessary supplies are available. identify the client's allergies. clarify the roles of the OR personnel. maintain the safety of the client.

maintain the safety of the client.

A nurse is evaluating the effectiveness of the preoperative education regarding pain control. Which statement by the client would indicate a need for further education? "I will push my PCA button before I get up to go to the bathroom." "I will have my wife push the PCA button when I'm asleep." "I will bring my favorite music to listen to after my surgery." "I will make sure to drink plenty of water so I don't get constipated from the pain medication."

"I will have my wife push the PCA button when I'm asleep."

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement requires immediate nursing intervention? "I will rescue clients from harm before doing anything else." "After clients are evacuated from the room with the fire, the alarm can be sounded." "I will close the door to the room where the fire is after clients have been removed." "Only certain members of the health care team can extinguish a fire."

"Only certain members of the health care team can extinguish a fire."

A child has been home from camp for 2 weeks and reports a sore throat, low-grade fever, and enlarged cervical lymph nodes. After testing, it is determined the child has Epstein-Barr virus (EBV)-associated infectious mononucleosis. The parent asks, "How did my child acquire this type of infection?" Which is the best response by the nurse? "The only way to acquire this infection is if the child was kissing another person." "The child may have acquired the infection when bitten by a mosquito." "The infection is acquired primarily through contact with infected oral secretions." "The infection is acquired primarily through contacted with infected blood."

"The infection is acquired primarily through contact with infected oral secretions."

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 visual field deficits Related to difficulty swallowing Related to impaired balance Related to psychomotor seizures

Related to impaired balance

A client diagnosed with osteoporosis is being discharged home. Which priority education should the nurse should provide? Remove all small rugs from the home Participate in weight-bearing exercises Classify medications Increase calcium and vitamin D in the diet

Remove all small rugs from the home

The first physical line of defense in innate immunity is: Skin and mucous membranes Plasma proteins Specialized lymphocytes Neutrophils

Skin and mucous membranes

A nurse is caring for the following clients. Which client should the nurse evaluate first? A 53-year-old female reporting an inability to fall sleep A 47-year-old male undergoing a sleep study A 23-year-old female diagnosed with periodic limb movement disorder (PLMD) An 18-year-old male who appears to be sleepwalking in the hallway

An 18-year-old male who appears to be sleepwalking in the hallway

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? Reprimand the parents for allowing the identification bands to come off. Replace the identification bands. 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. Obtain the neonate's footprints and compare them with the footprints obtained at birth.

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 reviewing a health care provider's orders in the electronic health record (EHR) and notices several abbreviations. What is the appropriate nursing action? Fix the abbreviations in the EHR. Confirm the abbreviations with another nurse. Administer medications as ordered. Contact the health care provider to clarify the orders.

Contact the health care provider to clarify the orders.

The nurse is caring for a client after surgery. The surgeon has written "resume pre-op meds" as an order on a client's chart. What should the nurse do next? Contact the surgeon for clarification because this is not a complete order. Transcribe the preoperative medication orders the surgeon has ordered. Ask the pharmacist for a list of preoperative medications for the client. Obtain new orders for the client from the physician on call.

Contact the surgeon for clarification because this is not a complete order.

A healthcare worker has been exposed to the blood of an HIV-positive client and is awaiting the results of an HIV test. In the meantime, what precautions must the healthcare worker take to prevent the spread of infection? Limit interactions with people who are not HIV infected. Limit interactions with people who are already HIV infected. Follow the same sexual precautions as someone who has been diagnosed with AIDS. Quit their job and get admitted to a hospital or a cancer treatment center.

Follow the same sexual precautions as someone who has been diagnosed with AIDS.

The nurse is working with a group of clients during group therapy in the mental health unit. The nurse will likely use which method(s) for client identification? Select all that apply. Have the client state his/her name and date of birth. Use an admission armband. Ask staff to identify client after the client states their name. Match client picture from the computer. Ask bedside visitor to identify the client.

Have the client state his/her name and date of birth. Ask staff to identify client after the client states their name.

An adult client with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. The medical history reveals diabetes mellitus, hypertension, and pernicious anemia. The client underwent an appendectomy 20 years earlier and an aortic valve replacement 2 years before this admission. What history finding is a major risk factor for infective endocarditis? Race Age History of diabetes mellitus History of aortic valve replacement

History of aortic valve replacement

The nurse is teaching a group of health care workers about latex allergies. What reaction will the nurse teach the workers to be most concerned about with laryngeal edema? irritant contact allergic contact IgE-mediated hypersensitivity IgG antibodies

IgE-mediated hypersensitivity

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? Use standard precautions, which require gloves for suctioning. Put on gloves, a mask, and eye protection. Put on gloves, a mask, and eye protection during suctioning, and then apply a mask to the client's face for transport. Take no special precautions 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. Bacterial meningitis is spread through contact with infected droplets. The nurse should wear gloves, a mask, and eye protection when suctioning the client. Additionally, the client should wear a mask when out of the isolation room for diagnostic testing.

Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients with which two diagnoses are appropriate to room together, based on safety and infection control standards? Clostridium difficile and diabetic ketoacidosis Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD) Tuberculosis and pneumonia Appendectomy and a draining leg ulcer positive for methicillin-resistant Staphylococcus aureus

Reactive airway disease and exacerbation of chronic obstructive pulmonary disorder (COPD)

A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse? Report the infection to an immediate supervisor. Ensure the infection is covered with a dressing. Return to work after taking antibiotics for 24 hours. Request a role change to circulating nurse.

Report the infection to an immediate supervisor.

The health care provider prescribes orders for a client with newly diagnosed uncontrolled seizure activity. When reviewing the prescriptions, the nurse correctly identifies that which prescription, if followed, puts him at risk for negligence charges? Neurologic assessments every 5 minutes Oxygen 2/L via nasal cannula Diazepam 5 mg intravenously now Restrain all four extremities

Restrain all four extremities

A new nursing graduate is working at the hospital in the medical-surgical unit. The preceptor observes the nurse emptying a patient's wound drain without gloves on. What important information should the preceptor share with the new graduate about standard precautions? Standard precautions should be used with all patients to reduce the risk of transmission of bloodborne pathogens. Standard precautions should only be used with patients who are HIV positive to reduce the risk of transmission of the HIV virus. It is only necessary to use gloves when you are emptying reservoirs that have body fluids in them. If you are careful and do not expose yourself to blood or body fluids, it is not necessary to use gloves all of the time.

Standard precautions should be used with all patients to reduce the risk of transmission of bloodborne pathogens.

The nurse is caring for a client that is suspected of having a latex allergy. What item of personal protective equipment should the nurse use with caution? Surgical masks Goggles Pillows Gowns

Surgical masks

Reproductive health education for women who are HIV-positive includes recommending which of the following contraceptives? Oral estrogen contraceptives An intrauterine device (IUD) A diaphragm The female condom

The female condom

A nurse exits the room of a confused client without raising the side rails on the bed. The failure to raise the side rails would constitute which element of liability related to malpractice? breach of duty duty causation damages

breach of duty

A client with erectile dysfunction who had a penile implant inserted has been taught how to identify malfunction of the device. Which of the following if stated by the client as indicative of malfunction would indicate to the nurse that the client has understood the teaching? Erosion of penile or urethral tissue Underinflation or bulging of the cylinders during inflation Erosion of scrotal, bowel, or bladder tissue Migration of the cylinders, pump, or reservoir from their intended location

Underinflation or bulging of the cylinders during inflation

The nurse on the elective surgery floor receives a report that describes the client's abdominal wound dressing as having a moderate amount of yellowish and bloody drainage on it and a very foul smell. In planning for a dressing change, it is most important for the nurse to perform which action? Change the abdominal dressing more frequently. Apply extra gauze dressings to the wound to absorb the drainage. Wash the nurse's hands before and after the dressing change. Use sterile gloves to change the abdominal dressing.

Wash the nurse's hands before and after the dressing change.

When developing the teaching plan for a client who uses a walker, which principle should a nurse consider? The hand bar of the walker should be well below the client's waist. When maximum support is required, the walker should be moved ahead approximately 6″ (15 cm) while both legs support the client's weight. If one leg is weaker than the other, the walker and the stronger leg should move, together, approximately 6″ ahead of the body. The client's weight is supported by his weaker leg. A standard walker needn't be picked up when moved.

When maximum support is required, the walker should be moved ahead approximately 6″ (15 cm) while both legs support the client's weight.

A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient? Within 24 hours after exposure Within 48 hours after exposure Within 72 hours after exposure Therapy is not necessary prophylactically and should only be used if the person develops symptoms.

Within 24 hours after exposure

The nurse will teach parents of children with myelomeningocele to maintain an environment free of what element? alcohol gel latex peanuts cat dander

latex A latex-free environment is important because research shows that up to 73% of children with repeated surgeries for spina bifida are sensitive to latex

Which nursing intervention is appropriate for a client with an arm restraint? applying the restraint loosely to prevent pressure on the skin tying the restraint to the side rail positioning the restrained arm in full extension monitoring circulatory status every 2 hours

monitoring circulatory status every 2 hours

A nurse is discussing sleep with a group of orienting unlicensed personnel. The nurse explains that the older adults can have issues with physical safety in relation to the sleep patterns because: they nap in the afternoon, which lessens their hours of sleep at night. they are typically prone to sleep walking. they are the age group least likely to use prescribed sleep medications. they may be disoriented on awakening.

they may be disoriented on awakening.

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? Avoid working in the garden or yard altogether. Wear gloves and protective clothing to avoid any injuries. Increase the frequency of follow-up visits if she does works. Avoid household chores for at least 6 to 9 months.

Wear gloves and protective clothing to avoid any injuries.

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 help protect you against infectious organisms." "Gloves guard you against my cold hands." "Gloves may protect me against infectious organisms." "Gloves are required for standard precautions."

"Gloves are required for standard precautions."

The nurse is preparing to administer medications. What action(s) will the nurse take when administering the medications? Select all that apply. uses a scanner on client band asks a bedside visitor to confirm client identification confirms client's name and date of birth by verbalization of client uses a picture identification and name band of a nonverbal client asks another staff member for client confirmation

confirms client's name and date of birth by verbalization of client uses a picture identification and name band of a nonverbal client