Safety Concept Unit Test 1

Which emergency response team helps set up shelters for victims who lost their homes due to a disaster?

American Red Cross

Which medication used to treat acne has a bleaching effect?

Benzoyl peroxide has a bleaching effect on sheets, bedclothes, and towels. Isotretinoin is associated with photosensitivity, nasal irritation, dry skin and mucous membrane. Minocycline and tetracycline are systemic antibiotics that may cause photosensitivity reactions, vaginal candidiasis, and gastrointestinal upset.

Atenolol

Beta blocker It can treat high blood pressure and chest pain (angina). It can also reduce the risk of death after a heart attack.

Which hospital department plays a primary role in disaster preparedness?

Emergency department The emergency department plays a primary role in emergency disaster preparedness. Although all departments in the hospital contribute to disaster planning, the only department that plays a primary role is the emergency department.

Which device should the nurse use to prevent external rotation of the hip when the patient is in a supine position?

Trochanter roll

Which is a primary symptom of gonorrhea?

genital discharge

Which priority intervention would the nurse use for a black widow spider bite in a prehospital setting?

Apply an ice pack on the bite area. The nurse would apply an ice pack on the area of the black widow spider bite in the prehospital setting. As a priority intervention for heatstroke, the nurse would immerse the victim in cold water. The nurse would use an IV form of epinephrine in case of bee and wasp stings. The nurse would assess the client for both orthostatic hypotension and tachycardia when the client is suffering from heat exhaustion.

The nurse is preparing to administer an intravenous piggyback antibiotic that has been newly prescribed. Shortly after initiation, the client becomes restless and flushed and begins to wheeze. After stopping the infusion, which priority action will the nurse take?

Assess the client's respiratory status. The client is experiencing an allergic reaction. Severe allergic reactions commonly cause respiratory distress as a result of laryngeal edema or severe bronchospasm. Assessing and maintaining the client's airway is the priority. The nurse must determine the client's status before notifying the primary health care provider. Vital signs, including blood pressure and pulse oximetry, are obtained after airway patency is ensured and maintained.

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

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

A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a very slow radial pulse of 44. Which nursing intervention is priority?

Assess the patient's apical pulse and evidence of a pulse deficit. The nurse's priority intervention is to assess the patient, determine the patient's apical heart rate, and determine if a pulse deficit exists. The nurse cannot delegate vital signs to an unstable patient. Calling for an ECG and administering cardiac-stimulating medications are interventions that require notification of the health care provider and occur after you assess the patient.

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

Examples of internal disasters that must be accounted for when formulating a disaster plan include fire and power outage. A hurricane and earthquake, both natural disasters, are classified as external disasters. An act of terrorism is also considered an external disaster.

Which occurs immediately after birth that increases the risk for cardiac decompensation in a client with a compromised cardiac system?

Extravascular fluid is remobilized into the vascular compartment. During the immediate period after birth the extravascular fluid is remobilized into the vascular compartment, increasing the client's risk for cardiac decompensation. At the moment of birth, the pressure on the veins is removed, the intra-abdominal pressure decreases dramatically, and the blood flow to the heart is significantly increased.

A patient reports having shortness of breath for 2 months. The nurse asks the patient to rate the shortness of breath on a scale of 0 to 10 and if it is affecting daily activities. The nurse also asks about exposure to passive smoking and if the patient feels comfortable when sleeping in a reclining chair. Which question asked by the nurse is about orthopnea?

If patient feels comfortable when sleeping in a reclining chair

The nurse is caring for a postsurgical patient. During a follow-up visit, the nurse finds that the patient has an infection at the surgical site. Which findings are consistent with the nurse's conclusion? Select all that apply.

Increase in pain increase in drainage Elevation in Temperature

Which findings in the laboratory reports of a patient indicate an upper respiratory tract infection?

Increased neutrophil count

A diabetic patient with poor glucose control has been admitted to the intensive care unit (ICU). The nurse observes that the patient is breathing deeply and the respiration rate is regular and increased. Which type of respiratory pattern is this patient exhibiting?

Kussmaul respiration

A patient has diabetic ketoacidosis. Which respiratory pattern is consistent with this condition?

Kussmaul respiration Kussmaul respiration is an abnormal pattern of breathing in which the respirations are abnormally deep, regular, and increased in rate. Kussmaul respiration is consistent with diabetic ketoacidosis. Hypoventilation is characterized by slow and shallow breathing, which is often seen in patients with a head injury or a drug overdose. Biot respiration is an abnormal pattern of breathing in which the respirations are abnormally shallow for two or three breaths followed by an irregular period of apnea. This pattern of breathing is seen in conditions such as meningitis and severe brain injury. Cheyne-Stokes respiration is characterized by rhythmic respirations, going from very deep to very shallow, with apneic periods. This pattern of breathing is seen in conditions such as heart failure, renal failure, or impending death.

Which part of the respiratory tract contains the vocal cords?

Larynx

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

Move the client to a private room. Contact precautions are used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment; therefore infectious clients must be placed in a private room. There is no need to insert an indwelling catheter, because this can increase the risk for additional infection. Droplet precautions are used for clients known or suspected to have infections transmitted by the droplet route. These infections are caused by organisms in droplets that may travel 3 feet but are not suspended for long periods.

Which condition would the nurse consider to require a high intensity of resources to provide effective care?

Respiratory distress A client in an Emergency Severity Index 1 (ESI-1) category, such as with severe respiratory distress, requires high resource intensity because it is a life-threatening condition. Clients with closed fractures are included in ESI-3, which requires moderate intensity resources because it is not a life-threatening complication. Low resource intensity is sufficient to care for clients with first-degree burns because immediate action may not be required. Clients with simple lacerations meet the criteria for ESI-4, and they do not require high-intensity resources.

The nurse understands which vaccine may cause intussusception in children?

Rotavirus Rotavirus vaccines very rarely cause intussusception, a form of bowel obstruction in which the bowel telescopes in on itself. Hepatitis vaccines can cause anaphylactic reactions. The measles, mumps, and rubella vaccine may cause thrombocytopenia. The diphtheria, tetanus, and pertussis vaccine carries a small risk of causing acute encephalopathy, convulsions, and a shock-like state.

A client who takes four 325-mg tablets of buffered aspirin four times a day for severe arthritis complains of dizziness and ringing in the ears. Which complication would the nurse conclude that the client probably is experiencing?

Salicylate toxicity Aspirin is a salicylate; excessive aspirin ingestion can influence the vestibulocochlear nerve (cranial nerve VIII), causing tinnitus and dizziness. The client is experiencing symptoms of toxicity, not an allergic response. Withdrawal symptoms occur when a medication is no longer being administered. Tolerance describes a condition in which additional medication is needed to achieve an effect; it is not associated with the development of new symptoms.

Which statement would the nurse know to be true regarding the characteristics of sarin?

Sarin can cause death within minutes of exposure. Sarin is a highly toxic nerve gas that can cause death within minutes of exposure. Mustard gas causes skin burns and blisters. A garlic-like odor and brown color are characteristics of mustard gas. Although pralidoxime chloride (2-PAM chloride) is used as an antidote for nerve agent poisoning, multiple doses may be needed to reverse the effects of nerve agents; also, sarin acts by paralyzing the respiratory muscles.

A medication has a minimum effective concentration of 25 mg/dL, and the therapeutic range is 25─100 mg/dL. Which plasma concentration may cause toxic effects of the drug? Record your answer using a whole number. ___________ mg/dL

The highest reading of a therapeutic range corresponds to the toxic range of plasma concentration. Any drug levels above this concentration are toxic. The highest value of the therapeutic range of the drug in question is 100 mg/dL, so plasma concentration of the drug above 100 mg/dL is toxic.

While obtaining a blood sample via a venipuncture, the nurse does not leave the tourniquet on for a long period of time. Why does the nurse perform this intervention?

To minimize the risk of hemoconcentration

In which patient would a resting heart rate of 55 beats per minute be considered a normal finding?

An athlete The conditioning of athletes, especially runners, allows a resting rate below 60 beats per minute without interrupting the normal sinus rhythm of the heart. A heart rate below 60 beats per minute is considered bradycardia. Athletes often maintain heart rates consistent with sinus bradycardia because their heart is an effective pump with a greater-than-normal stroke volume. An obese person may experience an increase in resting heart rate secondary to cardiac demand. Bradycardia is not associated with diuretics or weight less than 90 pounds.

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

Anxiety Nausea Sedation Restlessness Suicidal ideation Increased energy level Clients on SSRIs would be assessed for changes in attitude (anxiety, restlessness) and suicidal gestures. Depressed people may attempt suicide when taking antidepressants as a result of increased energy levels, which can lead to a renewed interest in suicide. Other side effects of SSRIs include nausea, sedation, dry mouth, vomiting, constipation, diarrhea, anorexia, differences in taste, headache, tremor, dizziness, weakness, fatigue, increased sweating, sexual dysfunction, visual disturbances, and urinary problems.

A child is administered a rotavirus vaccine. Which adverse medication effect would the nurse monitor for?

Intussusception In rare cases, rotavirus vaccine causes intussusception, a life-threatening form of bowel obstruction that occurs due to the bowel folding in on itself. The DTaP vaccine causes encephalopathy in rare cases. MMR vaccines induce thrombocytopenia in a few vaccinated clients. Meningococcal conjugate vaccines cause Guillain-Barré syndrome in some children.

Which level of trauma center provides a full continuum of care for the trauma client?

Level I Level I trauma centers are likely an urban academic center that provides the full continuum of care for the trauma client and conducts research for trauma center verification. Level II trauma centers provide care to most trauma clients and are located in the community hospital. Level III trauma centers stabilize and transfer trauma clients from the community hospital setting. Level IV trauma centers are likely rural with basic support that transfers out to a higher-level care center.

The nurse identifies which physiological alteration associated with pregnancy that may change the client's response to medication?

Longer gastrointestinal emptying time Gastrointestinal motility is reduced during pregnancy because of the high level of placental progesterone and displacement of the stomach superiorly and the intestines laterally and posteriorly; absorption of some medications, vitamins, and minerals may be increased because of their slow passage through the gastrointestinal tract. The glomerular filtration rate increases during pregnancy. The amount of gastric secretion is somewhat lower in the first and second trimesters; it increases in the third trimester. The development of fetal-placental circulation is unrelated to the absorption of medications.

Which symptom is characteristic of stress incontinence?

Loss of urine when coughing Loss of urine control during activities such as coughing that increase intraabdominal pressure indicates stress incontinence. A sudden urge to void indicates urge incontinence. A constant dribbling of urine indicates overflow incontinence. The inability to reach the toilet in time indicates functional incontinence.

Which enema helps treat local infections?

Medication Medication enemas may contain antibiotics that help treat local infections. Isotonic enemas expand the colon to promote peristalsis. Carminative enemas stimulate peristalsis and provide relief from gastric distention. Oil-retention enemas lubricate the rectum and colon to make the feces softer and easier to pass.

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

Modifying the home environment to prevent accidents

Which relationship reflects the relationship of naloxone to morphine sulfate?

Protamine sulfate to heparin Protamine sulfate is the antidote for heparin overdose, and naloxone will reverse the effects of opioids such as morphine. Aspirin and warfarin both interfere with coagulation. Although amoxicillin is used to treat some infections, an infection is not a medication, so amoxicillin cannot be considered an antidote. Both enoxaparin and dalteparin are low-molecular-weight heparins.

While assessing a patient's wound, the nurse looks for signs indicating a localized response to inflammation. Which objective and subjective signs does the nurse anticipate observing?

Pain Redness Swelling Inflammation is the body's localized response to cellular injury or infection that causes capillary dilation and leukocyte infiltration. Pain, swelling, redness, and heat at the local wound site results from capillary dilation and leukocyte infiltration in the body tissues. A laceration is a deep cut or a tear in the skin or flesh. It is a wound and can evoke an inflammatory response; it is not a sign of inflammation. An increase in temperature rather than decrease in temperature at the wound site is a protective inflammatory mechanism against infection.

Which nursing resource must be available to effectively meet potential needs during a disaster?

Preparation for disasters includes ensuring resources are available to meet potential needs. The nurse leader must ensure there is adequate staff, medication, hospital beds, medical devices such as mechanical ventilators, personal protective equipment

A woman experiences a rise in body temperature during ovulation. Which hormone is responsible for a rise in body temperature during ovulation?

Progesterone Ovulation is associated with the release of greater amounts of progesterone into the circulation, which is responsible for raising body temperature. Inhibin, estrogen, and luteinizing hormone have no role in raising body temperature. Inhibin inhibits the synthesis and secretion of follicle-stimulating hormone. Estrogen is the female sex hormone responsible for development of secondary sexual characteristics in females and regulation of the menstrual cycle. Luteinizing hormone triggers the process of ovulation.

A patient has a disease that is transmitted via airborne particles. Which medical diagnosis would the nurse observe written in the chart?

tuberculosis

A child ingests a substance that may be a poison, and the parent calls the nurse to ask what to do. Which is the best response by the nurse?

"Call the Poison Control Center." The Poison Control Center has the most current and up-to-date information on how to treat any type of poisoning. Also, the center can advise the parent whether to bring the child to the hospital and what data to collect to bring to the hospital, if this becomes necessary. Administration of syrup of ipecac is no longer recommended by the American Academy of Pediatrics. A potential poisoning may or may not require emergency intervention; with expert advice the child may be treated in the home. Also, the experts at the Poison Control Center can provide advice about initial interventions at home before going to the hospital. No treatment should begin before obtaining information about the amount and kind of substance ingested and the advice of a health care provider.

The registered nurse (RN) is giving home care instructions to a client who was treated for injuries due to a fall. Which statement made by the client indicates a need for additional instruction?

"I should walk on soft scatter rugs at home."

A patient with hematuria is scheduled for cystoscopy. Which instruction does the nurse give to the patient after cystoscopy?

"increase your fluid intake"

The nurse is caring for a patient with esophageal cancer who is about to receive an initial nasogastric tube feeding. Which nursing intervention best ensures safe and effective treatment in the patient?

Confirming tube placement through radiography

A client is receiving haloperidol for agitation, and the nurse is monitoring the client for side effects. Which response identified by the nurse is unrelated to an extrapyramidal tract effect?

A hypertensive crisis is not associated with extrapyramidal tract symtoms. Akathisia, characterized by restlessness and twitching or crawling sensations in the muscles, is an extrapyramidal side effect. Opisthotonos, characterized by hyperextension and arching of the back, is an extrapyramidal side effect. Oculogyric crisis, characterized by the uncontrolled upward movement of the eyes, is an extrapyramidal side effect.Test-Taking Tip: Work with a study group to create and take practice tests. Think of the kinds of questions you would ask if you were composing the test. Consider what would be a good question, what would be the right answer, and what would be other answers that would appear right but would in fact be incorrect.

Which conditions may result from immunoglobulin IgE antibodies on mast cells reacting with antigens? Select all that apply. One, some, or all responses may be correct.

Asthma Hay Fever Clinical conditions such as asthma and hay fever are considered type I hypersensitive reactions mediated by a reaction between IgE antibodies with antigens. Type I hypersensitivities result in the release of mediators such as histamines. Type IV hypersensitivity reactions such as sarcoidosis are a result of reactions between sensitized T cells and antigens. Myasthenia gravis results from a type II hypersensitivity reaction due to an interaction between immunoglobulin IgG and the host cell membrane. Rheumatoid arthritis is a type III hypersensitivity reaction resulting in inflammation from the formation of immune complexes between antigens and antibodies.

A primary health care provider prescribes atenolol 20 mg by mouth four times a day. Which information is important for the nurse to include in the discharge teaching plan for this client?

Avoid abruptly discontinuing the medication.

A patient has abnormally shallow respirations followed by irregular periods of apnea. Which term does the nurse use to record this breathing pattern?

Biot respiration

The nurse understands that patients with dysrhythmias may have a pulse deficit. Which statement describes how a nurse should calculate the pulse deficit?

Calculate the difference in pulse rate of apical and radial pulse. A pulse deficit is created when an inefficient contraction of the heart fails to transmit a pulse wave to the peripheral pulse site. Pulse deficit is the difference of apical and radial pulse rate. There is usually no difference in left and right radial pulse rate or in left and right femoral pulse rate. A pulse deficit does not indicate the difference of radial and femoral pulse rate.

When a client who is taking a diuretic has been instructed to eat foods high in potassium, which fruit would the nurse suggest?

Cantaloupe is high in potassium. Apples are low in potassium. Grapes are not a good source of potassium. Cranberries are low in potassium.

Which is the critical factor among health care professionals, state agencies, and federal agencies to determine when and how to evacuate safely during a natural disaster?

Communication Communication is the critical factor among health care professionals, state agencies, and federal agencies to determine when and how to evacuate safely during a natural disaster. Cooperation, classification, and collaboration, although important, are not the critical factors to determine when and how to safely evacuate during a natural disaster.

A nurse is administering an eye medication that removes secretions and cleanses and soothes a patient's eye. Which type of ophthalmic medication is the nurse administering?

Eye irrigation

Which entity is responsible for activating the disaster plan during a mass casualty incident (MCI)?

Federal emergency management agency Response to MCIs often requires the aid of a federal agency. The National Incident Management System (NIMS) is a section within the U.S. Department of Homeland Security. NIMS is responsible for coordinating federal, state, and local government efforts to respond to and manage domestic MCIs. Local emergency management systems may communicate with the hospital from the field to determine how many clients the hospital can accept.

To what angle should the nurse elevate the head of the examination table for patient comfort at the beginning of a standard physical examination?

For optimal patient comfort on an examination table, the head of the table should be raised to 30 degrees and a small pillow (or towel) offered for support under the patient's head. Examination tables are often very firm and unsupportive when the patient lies supine. Elevation to 30 degrees promotes relaxation and is generally tolerated by patients with shortness of breath.

Punctal occlusion is performed after the administration of eyedrops to prevent which from occurring?

Systemic absorption Punctal occlusion prevents systemic absorption of the medication. For example, systemic absorption of beta-blockade used to treat glaucoma can affect heart rate and blood pressure. Punctal occlusion does not prevent tearing, infection, or allergic reaction.

intussusception

a serious condition in which part of the intestine slides into an adjacent part of the intestine. This telescoping action often blocks food or fluid from passing through. Intussusception also cuts off the blood supply to the part of the intestine that's affected.

Which action would the nurse take while a client is seizing on the hallway floor?

protect the client's head from injury