Safety/Infection
A nurse is preparing to give a bed bath to an immobilized client with tuberculosis (TB). The nurse should plan to wear which of the following items when performing this care?
Particulate respirator, gown, and gloves
A 9-year-old child with leukemia is in remission and has returned to school. The school secretary calls the mother of the child and tells the mother that a classmate has just been diagnosed with varicella (chickenpox). The mother immediately calls the nurse at the health care provider's office because the leukemic child has never had chickenpox. The nurse makes which response to the mother?
"Bring the child to the office for a gamma globulin injection." Immunocompromised children are unable to adequately fight varicella. Varicella can be deadly to the immunocompromised child. If an immunocompromised child who has not had chickenpox is exposed to someone with varicella, the child should receive varicella zoster immune globulin (VZIG) within 96 hours of exposure.
A client is seen in the health care clinic, and a diagnosis of conjunctivitis is made. The nurse provides discharge instructions to the client regarding care of the disorder while at home. Which statement by the client indicates a need for further instruction?
"I do not need to be concerned about spreading this infection to others in my family.
A child is diagnosed with viral conjunctivitis and antibiotic eye drops are prescribed for the child. The mother asks the nurse when the child can return to school. The nurse makes which response to the mother?
"The child should be kept home until the antibiotic eye drops have been administered for 24 hours."
Which specific instruction should be included in the teaching plan for a mother whose newborn is human immunodeficiency virus (HIV)-positive?
Instruct the mother and family to provide meticulous skin care to the newborn and to change the newborn's diaper after each voiding or stool.
A nurse is assigned to the care of a client with an unsealed internal radiation source. During an 8-hour shift, the nurse plans the care to avoid spending more than how much time in the client's room?
30 minutes
A nurse assists a health care provider with the insertion of a Miller-Abbott tube. After insertion of the tube, the nurse should assist the client to which of the following positions?
A Miller-Abbott tube is an intestinal tube that has a double lumen, one for a tungsten balloon and the other for suction or drainage. After insertion of the tube, the tube is allowed to advance for several hours. The client is positioned in High Fowler's and on the right side to facilitate passage through the pylorus of the stomach and into the small intestine. Options 1, 2, and 4 are incorrect.
A client with methicillin-resistant Staphylococcus aureus (MRSA) needs to be placed on contact precautions, and the licensed practical nurse (LPN) in charge asks a newly licensed LPN to initiate contact precautions. Which action by the new LPN would indicate the need to review the procedure for contact precautions?
A client with methicillin-resistant Staphylococcus aureus (MRSA) needs to be placed on contact precautions, and the licensed practical nurse (LPN) in charge asks a newly licensed LPN to initiate contact precautions. Which action by the new LPN would indicate the need to review the procedure for contact precautions?
A nurse is assigned to assist with caring for a client with esophageal varices who has a Sengstaken-Blakemore tube inserted. The nurse checks the client's room to ensure that which priority item is at the bedside?
A pair of scissors
A client is being transferred to the nursing unit from the postanesthesia care unit following spinal fusion with rod insertion. The nurse should prepare to transfer the client from the stretcher to the bed by using:
A slider board and the assistance of four people
A nurse is preparing to provide mouth care to an unconscious client. The nurse collects which items to perform this procedure?
A soft toothbrush Oral suction catheter Bite stick or a padded tongue blade Mouthwash
A nurse has a prescription to obtain a sample for urinalysis from a client with an indwelling urinary catheter. To prevent contamination of the specimen, the nurse would avoid which action?
A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag and does not necessarily reflect current client status. In addition, it may become contaminated with bacteria from opening the system.
An emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the emergency department. Which of the following would be the initial nursing action?
Activate the agency disaster plan
A nurse is caring for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On data collection, the nurse notes that the client is severely dysphagic. The nurse should include which of the following in the plan of care?
Allowing the client sufficient time to eat Providing oral hygiene after each meal Maintaining a suction machine at the bedside
A nurse who is employed in a long-term care facility is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster?
An experienced nursing assistant who has never had chickenpox
A nurse plans to change the dressing of the client who has had arterial bypass surgery. Which technique is important for the nurse to follow?
Aseptic technique
A nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the nurse inflates the balloon, the client complains of discomfort. The appropriate nursing action is to
Aspirate the fluid, advance the catheter farther, and reinflate the balloon.
A nurse is assigned to assist in caring for a client who has had an autograft placed on the lower extremity. The nurse plans to:
Autografts placed over joints or on lower extremities are often elevated and immobilized after surgery for 3 to 7 days. This period of immobilization allows the autograft time to adhere and attach to the wound bed
A nurse is changing the abdominal dressing on a client following a suprapubic prostatectomy. A Penrose drain is in place in the abdominal wound. Which nursing action would be appropriate during the dressing change?
Checking the wound site for drainage from the drain Usually the drainage from the wound is pale, red, and watery. Active bleeding is bright red. Aseptic technique must be used when changing the dressing to avoid contamination of the wound, and sterile gloves are worn. The drain should be checked for patency to provide an exit for the fluid and blood to promote healing. The drainage needs to flow freely, and there should be no kinks in the drains. Curling, folding, or taping the drain prevents the flow of drainage. The tube is not advanced.
An outbreak of illness has occurred in a community and is suspected to be related to food ingestion. A community health nurse places priority on which intervention?
Determining what common food item was ingested by those affected
A nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement:
Droplet precautions
A nurse is caring for a client who has hand restraints. The nurse assesses the skin integrity of the restrained hands:
Every 30min
A child has been diagnosed with meningococcal meningitis. Which of the following isolation techniques is appropriate?
Isolation precautions for at least 24 hours after the initiation of antibiotics
A nurse is assigned to care for a client on contact precautions. On review of the client's record, the nurse notes that the client has a hospital-acquired infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator and requires frequent suctioning. The nurse gathers supplies before entering the client's room and obtains which necessary protective items?
Gloves, mask, gown, and goggles Goggles are worn to protect the mucous membranes of the eye, and a mask is worn to protect the mouth and respiratory system during interventions that may produce splashes of blood, body fluids, secretions, and excretions. In addition, contact precautions require the use of gloves and a gown to be worn if direct client contact is anticipated. Shoe protectors are not necessary.
A nurse prepares to give a bath and change the bed linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which of the following should the nurse use during the bathing of this client
Gown and gloves
A nurse is instructed to complete a medication reconciliation form on a newly admitted client. Why is it important for the nurse to ensure that this process is completed accurately?
It helps to make sure that the health care provider is aware of all of the medications the client is taking and has been taking at home.
A nurse is preparing to change the neck ties on a tracheostomy tube. To perform this procedure, the nurse should plan to:
It is best to have two people help change the ties on a tracheostomy. The movement of the tube can easily cause the client to cough and expel the tube from the stoma. Removing the old ties, cleaning the site, and then applying the new ties is not appropriate because if the client coughs, the tube could be expelled. This procedure is a nursing procedure; therefore, it is not appropriate to call the HCP. The respiratory therapist can assist in changing the ties, but it is not necessary to specifically call the therapist for the procedure.
A nurse is caring for a homebound older postoperative cardiovascular client. The caregiver's daughter states to the nurse, "My mother has fallen out of bed three times." Which observation by the nurse would indicate the need for intervention to ensure safety?
Leaving a side rail down on the bed of an older client increases the risk of falling. The aging process also increases this client's potential for falls; therefore evaluating the safety of the environment is a necessity.
A health care provider (HCP) has written a prescription for a preoperative client to have "enemas until clear." The nurse has administered three enemas and the client is still passing brown liquid stool. Which action should the nurse take next?
Notify the HCP.
The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which of the following data specifically associated with this therapy before the initiation of therapy?
Pedal pulses Capillary refill Color of the extremity Temperature of the skin
A nurse assists in developing a plan of care for a client who will be hospitalized for insertion of an internal cervical (vaginal) radiation implant. Which of the following should the nurse suggest including in the plan of care for the client?
Place a radiation sign on the door outside of the client's room.
A nurse is caring for a client at risk for postpartum endometritis. Which nursing intervention would minimize this risk following delivery?
Postpartum endometritis is frequently associated with the invasion of bacteria that may arise from the gastrointestinal tract or the lower genital tract. Reviewing appropriate handwashing techniques and pericare with the client during the postpartum period would reduce the risk of possible bacterial invasion of the myometrium.
A nurse is assigned to reinforce instructions to a client and the family about the management of home intravenous (IV) infusion therapy. The nurse begins the process by first teaching the client and family principles related to:
Proper handwashing technique
When performing an assessment of the client's skin, the nurse notes the presence of multiple straight and wavy threadlike lines beneath the skin and suspects the presence of scabies. Which of the following precautions will the nurse institute before completing the assessment of the client?
Put on a gown and gloves
A nurse is reinforcing teaching provided to a client with a continuous passive motion (CPM) machine. The nurse determines that the client needs further instructions when the client states that he will:
Reset the degrees of flexion or extension according to comfort. The client is instructed to stop and start the CPM device and leave the padding in the device for leg protection. The client should be taught proper positioning and alignment. The client should not try to adjust the flexion and extension settings. These are decided on by the orthopedic surgeon and are maintained as prescribed.
A nurse provides instructions to the parents of a newborn infant regarding car travel and safety seats. Which of the following is the correct information related to the safety of the infant?
Restrain in a car seat in the back seat in a semireclined, rear-facing position.
A nurse is caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding preventing the transmission of the infection to the other children in the family and the other household members and tells the mother which of the following?
Roseola is transmitted via saliva; therefore others should not share drinking glasses or eating utensils
A nurse is preparing to get a client with tetraplegia (quadriplegia) out of bed into a chair. The nurse places which item on the seat of the chair as the best device for pressure relief?
The client who cannot independently shift weight should have a pressure relief pad in place under the buttocks to prevent skin breakdown. The best products for use in providing pressure relief are those that equalize the client's weight on the device. These include foam, water, gel, or alternating air pads. A plastic-lined pad absorbs moisture but provides no pressure relief. A pillow provides cushion but does not redistribute weight equally. An air ring relieves pressure in some spots but causes pressure in others by its design.
A nurse is teaching the paraplegic client measures to promote skin integrity. Which instruction(s) will be helpful to the client?
To prevent pressure ulcers from developing, the paraplegic client should shift weight in the wheelchair at least every 2 hours and use a pressure relief pad. While in bed, the bottom sheet should be free of wrinkles and wetness. The client should use a mirror to inspect the skin twice a day (morning and evening) to assess for redness, edema, and breakdown. Additional general measures include a nutritious diet and meticulous skin care.
A nurse reviews the laboratory values on a child with leukemia receiving chemotherapy. The nurse notes that the platelet count is 19,000/mm3. Based on this laboratory result, which of the following will the nurse include in the plan of care?
Using a soft toothbrush for mouth care If a child is severely thrombocytopenic, with a platelet count less than 20,000/mm3, precautions need to be taken because of the increased risk of bleeding. The precautions include limiting activity that could result in head injury, using soft toothbrushes, checking urine and stools for blood, and administering stool softeners to prevent straining with constipation. Additionally, suppositories and rectal temperatures are avoided. The incorrect options relate to the prevention of infection rather than bleeding.
A school nurse prepares a list of home care instructions for the parents of school children who have been diagnosed with pediculosis capitis (head lice). Which is included in the list?
Vacuum floors, play areas, and furniture to remove any hairs that may carry live nits.
A nurse is giving a client a bed bath and drops the towel on the floor. The nurse should take which action?
Wash the hands and go to the linen room to obtain another towel.
The parent of a toddler asks a nurse when it is safe to place the car safety seat in a face-forward position. Which of the following is the best nursing response?
When the toddler weighs 20 lb and is 1 year old
A nurse is caring for a child following a tonsillectomy who has wrist restraints in place. The nurse assists in preparing a plan of care and determines that which nursing intervention should receive highest priority regarding the restraints?
Checking color, sensation, and pulses distal to the restraint
The nurse determines that the client understands the proper fitting of the crutches when he states that the space between the axilla and the top crutch pad should be:
The client should have a distance of 1½ to 2 inches between the axilla and the top of the crutch pad to prevent injury to the brachial nerve plexus while maintaining proper support. This measurement should be taken with the client holding the crutches with the elbows bent at a 30-degree angle. The other options are incorrect.
A nurse is observing a nursing student preparing to obtain a throat culture on a client suspected of having a beta-hemolytic Streptococcus infection. Which of the following indicates the need to further educate the student regarding collecting this specimen?
Asking the client to tilt the head forward and to open the mouth Placing the collection swab initially at the back of the client's throat When collecting a throat culture, the client is told that the test is performed to help identify microorganisms causing the symptoms. The client is instructed to tilt the head back, and both the tonsillar pillars and the posterior pharynx wall are swabbed. A tongue depressor is used in the collection so that the swab is less likely to contact the normal flora of the mouth. The swab is immediately placed in a labeled culture tube and transported to the laboratory.
A nurse is preparing to administer a measles, mumps, rubella (MMR) vaccine to a 15-month-old child. Before administering the vaccine, which of the following questions would the nurse ask the mother of the child?
Before administration of the MMR vaccine, a thorough health history must be obtained. MMR is used with caution in a child with a history of an allergy to gelatin, eggs, or neomycin because the live measles vaccine is produced by chick embryo cell culture and MMR also contains a small amount of the antibiotic neomycin
A pregnant human immunodeficiency virus (HIV)-positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. The nurse determines that additional guidance is needed if the woman states that she will
Breast-feed, especially for the first 6 weeks postpartum.
An adolescent client is admitted to the hospital following an accidental gunshot wound to the foot. The nurse should plan to do which of the following as a first step for the prevention of future injury?
Explore the adolescent's knowledge of gun safety.
A nurse is preparing to administer a continuous tube feeding to a client with a nasogastric tube. The health care provider has prescribed an amount of 100 mL/hr. The nurse plans to fill the feeding bag with:
Feeding can be hung at room temperature for a period of 4 hours. If 100 mL/hr is prescribed, the nurse would fill the feeding bag with a maximum amount of 400 mL. Feeding hung longer than 4 hours at room temperature creates the risk of bacterial invasion in the formula.
A nurse is preparing to reposition a dependent client who weighs more than 250 pounds. What intervention is best for the nurse to consider when moving this client?
Get Help. Although it is possible to move and position clients independently, getting help first is the best intervention. Lower back strain is a common injury among health care workers. In addition, the shearing of the client's skin over bony prominences may occur when health care workers move clients independently. Administering oral pain medication is necessary, but oral medications need to be given at least 30 to 45 minutes before clients are moved. Keeping the elbows close and working close to the body are useful techniques, but they would not be enough when independently moving a 250-pound client. This client is dependent, so he or she is probably not able to help much, if any.
A nurse is caring for a client with a health care-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which of the following protective items will be required to perform this procedure?
Gloves, a gown, and goggles
A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed linens changed. The nurse should wear which of the following to perform these tasks?
Gowns and gloves are required if the nurse anticipates contact with body fluids, such as wound drainage, diarrhea, or ileostomy or colostomy drainage.
A hospital employee is removing trash from a nursing unit and accidentally pricks a finger with a needle that was discarded in the trash. The employee never received the hepatitis B vaccine and asks the nurse what can be given to him for protection. The nurse tells the hospital employee that which of the following will be administered?
Hepatitis B immune globulin and hepatitis B vaccine Immune globulin is given prophylactically for hepatitis A. Hepatitis B immune globulin is indicated for persons exposed to the hepatitis B virus. Vaccination is effective for long-term prevention of hepatitis B in health care workers. Both the vaccine and hepatitis B immune globulin may be given at the same time. Because the hospital employee was pricked by a needle from an unknown source, both vaccine and hepatitis B immune globulin will be administered.
A 5-week-old infant is brought to the well-baby clinic by the mother because the mother has noted white patches in the infant's mouth. Following assessment, the infant is diagnosed with oral candidiasis (thrush). Nystatin oral suspension is prescribed. The mother is concerned because she is breast-feeding the infant and asks the nurse if breast-feeding can be continued. Which of the following responses is appropriate?
If an infant with thrush is being breast-fed, the mother's breasts should also be treated with nystatin.
A nurse is caring for a client who is on airborne precautions. The nurse notes that the client is scheduled for a magnetic resonance imaging (MRI) test. Which of the following nursing actions would be most appropriate in preparing the client for the test?
If the client is on airborne precautions, client movement and transport should be limited if possible. If transport or movement is necessary, client dispersal of droplet nuclei can be minimized by placing a surgical mask on the client.
The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula. To provide a safe and effective delivery of the oxygen the nurse avoids which of the following?
If the tubing is attached to the client's bed linen, it will become dislodged from the nares whenever the client moves. The tubing should have sufficient slack and be secured to the client's clothes. Keeping the humidification jar filled will help prevent the client from breathing dehumidified oxygen. The nares should be checked frequently because oxygen will dry the nasal mucosa. Oxygen is a medication and its prescription should be verified every shift to ensure the correct rate.
In preparing to care for a hospitalized child with a diagnosis of measles (rubeola), which supplies would the nurse bring to the child's room to prevent the transmission of the virus?
Mask and gloves Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Respiratory isolation is required, and a mask should be worn by those in contact with the child. Gloves should be worn to prevent transmission via direct contact. Gowns and goggles are not specifically indicated for care of the child with rubeola. Any articles that are contaminated should be bagged and labeled.
A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measure is necessary when caring for this client?
Monitoring the skin around the stoma site for skin irritation A gastrostomy tube is a tube inserted directly into the stomach for the purpose of providing direct enteral nutrition. Because of the surgical incision, occasionally gastric contents leak out onto the client's skin. Gastric contents are highly acidic and can cause major skin irritation, which may lead to infection. The nurse must monitor the insertion site for skin irritation. Option 1 is incorrect and generally the client with a G-tube is unable to tolerate oral intake. Antidiarrheal medications are not administered every day. Clean, not sterile, technique is needed in caring for the client.
After attending the same social function 5 days ago, 50 individuals arrive at the hospital over a 4-day period with fever; an itchy, reddish brown papule; and complaints of nausea, vomiting, and severe abdominal pain. Cutaneous anthrax is suspected by the health care team Which of the following is the nurse's priority for client care?
The clients present with clinical indicators consistent with cutaneous anthrax. This form of anthrax is highly contagious, and the nurse must institute contact precautions because Bacillus anthracis is transmitted by direct contact, flies, and fomites (option 1). Once contact precautions are in place, the remaining treatment should commence immediately because delayed treatment increases the risk of mortality. Anthrax vaccine may be administered to clients with cutaneous anthrax (option 2) because this form of anthrax does not confer acquired immunity and because the toxins potentially released from B. anthracis can be lethal. Ciprofloxacin is the medication of choice for anthrax infection and pharmacotherapy can last for 60 days (option 3). Frequent vital signs are needed for early detection of shock (option 4).
A camp nurse is providing instructions to the parents of the children who are attending a daytime camp for the summer. The nurse instructs the parents to check their child daily for the presence of tick bites and tells the parents that if a tick is found to first
The method to remove ticks includes suffocating the tick with nail polish, petroleum jelly, or oil, and waiting 30 minutes. The tick is then removed with tweezers, taking care to remove the head. If mouth parts remain, they are removed with a sterile needle. The area is then washed with soap and water. It is premature to instruct the parents to take the child to the emergency department.
A nurse is assigned to care for a client who has been diagnosed with human immunodeficiency virus (HIV). In planning care for the client, the nurse understands that educating staff concerning which of the following will have the greatest impact on minimizing the spread of the virus?
Using personal protective equipment appropriately HIV is a blood-borne illness with a long latency period between the introduction of the virus and positive results on a blood test. This makes it unrealistic and unreliable to test every client on a hospital unit. Testing every client is also questionable from an ethical perspective. Protective isolation is meant to protect the client with a decreased immune function, not to protect the nurse. HIV is not a virus that is transmitted by the airborne route. The Centers for Disease Control and Prevention guidelines are specific regarding when and how to use protective equipment and are a nurse's best protection
A client with tuberculosis (TB) who is being prepared for discharge to home should be instructed to do which of the following to decrease the possibility of spreading the infection?
Wear a mask when in contact with people outside of the family, until medications are effective. In the home situation, family members are best protected by careful handwashing. Because they are already exposed, masks would not be of much benefit. However, masks to protect people outside of the family can be beneficial and should be recommended. Sputum cultures may be prescribed to evaluate the effectiveness of therapy but not on a weekly basis. BCG is a vaccine that produces increased resistance to TB and is recommended in areas where there is a high rate of TB, but it renders future skin tests invalid in those who receive it.
The nurse prepares the client for irrigation of an abdominal wound. (Click on the Question Video button to view a video showing preparation procedures.) After preparation, the nurse would appropriately don which of the following items to perform the procedure?
Gloves, gown, and goggles
A mother brings her child to the health care clinic because the child has developed lesions located around the mouth and nose, and mild impetigo is diagnosed. The nurse provides instructions to the mother regarding care of the child. Which statement by the mother indicates the need for further instructions?
Impetigo is extremely contagious and may spread to other parts of the child's skin or to others who touch the child, use the same towel, or drink from the same glass. Lesions should be washed gently three times a day with a warm, soapy facecloth and crusts soaked and carefully removed. Mild cases are treated with topical antibiotic ointment. The topical antibiotic ointment is applied to the lesions after they are washed. Severe cases are treated with oral antibiotics.
A registered nurse is preparing to insert a nasogastric (NG) tube in a client and asks the licensed practical nurse (LPN) to obtain supplies needed for the procedure. Which of the following supplies, if obtained by the LPN, indicates a need for teaching regarding this procedure?
Oil lubricant
A nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which of the following should the nurse include in the preparations?
Open the distal flap of a sterile package first. Prepare the sterile field just before the planned procedure. Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field.
A pulmonary angiography is scheduled for a client suspected of having a pulmonary embolism. The nurse understands that which of the following is an appropriate pre-procedure care intervention?
Shave the anticipated entry site. Obtain a signed informed consent form. Inquire whether the client has any allergies to shellfish. Ask whether client has ever experienced an allergy to any contrast media. A pulmonary angiography is not performed in the operating room; therefore it is not necessary that the nurse contact this department. An informed consent form is required. The procedure is explained to the client, and the client is asked about allergies to shellfish or contrast media. Oral ingestion, except for sips of water, is avoided for 4 to 6 hours before the test. After the informed consent form is signed, the nurse shaves and prepares the anticipated entry site.
A client with chronic pain has been taught how to operate a transcutaneous electrical nerve stimulation (TENS) unit. The nurse determines that the client understands the appropriate use of the device when the client reports that the level of stimulation is uncomfortable and then:
The client applies a TENS unit by placing two electrodes on the skin and adjusting the level of stimulation to one lead at a time. The amount of stimulation is increased until the client feels discomfort, which indicates that the maximal stimulation necessary to block painful stimuli has been reached. The volume is then reduced slightly until no further discomfort occurs. The other options are incorrect.
A nurse is collecting data from a client and is observing the client ambulate with the use of a cane. The nurse would intervene and suggest a physical therapy referral if the nurse observed that:
The client should move the cane and the affected side together. The cane helps to support the affected side as it moves forward. It also helps the client to maintain balance. The client holds the cane on the unaffected side to shift the client's weight away from the affected side. The client holds the cane close to the body to prevent the client from leaning. The cane's handle should reach the level of the greater trochanter of the client's femur with a 25- to 30-degree flexion at the client's elbow.
A nurse is told that a client will be admitted to the hospital for a radiation implant for bladder cancer. The nurse is asked to prepare for the admission of the client and plans which priority measure for this client?
The client who has a radiation implant is placed in a private room, which is often located near the end of the hall. These measures enhance radiation safety by reducing exposure for others in the clinical unit. The client also has limited visitors for the same reason. Reverse isolation is unnecessary.
A nurse is preparing to initiate a tube feeding for a client, and the health care provider has prescribed the use of an electronic feeding pump. The nurse brings the pump to the bedside to plug the pump cord into the wall and discovers that there is no available outlet in the wall socket. Which of the following should be the appropriate nursing action
The nurse needs to use hospital resources for assistance. A regular extension cord should not be used because it poses the risk of fire. The use of electrical appliances near a sink also presents a hazard. If the use of a pump is prescribed, the nurse must provide safe means for its use.
A nurse has instructed a client in safety measures while using oxygen in the home. The nurse determines that the client needs additional instructions if the client verbalized to:
The oxygen concentrator is kept slightly away from the walls and corners to permit adequate airflow. The use of electric razors or other equipment that could emit sparks should be avoided while oxygen is in use. This could result in fire and injury to the client. Therefore a straight razor is used for shaving. The client should follow the oxygen prescription exactly and should not allow smoking or any type of flame within 10 feet of the oxygen source. Other measures include keeping the source out of direct sunlight; having telephone numbers for the health care provider, nurse, and oxygen vendor available; and teaching the client signs and symptoms requiring emergency care.
The nurse enters the room to find that the client's trash can is in flames. The nurse should take which action first?
The principles of fire safety can be easily remembered by recalling the acronym, RACE. This stands for "rescue" (option 3), "alarm" (option 2), "confine" (or "contain"), and "extinguish" (options 1 and 4).
A nurse conducts a home safety assessment with a client preparing for discharge, and the client tells the nurse that a space heater is used to heat the apartment. Which of the following instructions should the nurse provide to the client regarding the use of the space heater?
The space heater needs to be placed at least 3 feet from anything that can burn.
A nurse in a health care provider's office receives a telephone call from the mother of a child who tells the nurse that the child was just stung by a bee. The mother asks the nurse for instructions regarding removal of the stinger. Which of the following instructions should the nurse provide to the mother?
The stinger from a bee should be removed carefully by scraping it out horizontally. The mother should be instructed to avoid squeezing the stinger because more venom will be released. Following removal of the stinger, the area is washed with soap and water, and ice may be applied for discomfort.
In developing a plan of care for a client hospitalized with tuberculosis (TB) the nurse would place emphasis on which intervention?
The strict adherence to following airborne precautions Tuberculosis is a respiratory infection that requires the use of airborne precautions to prevent transmission of infection. Planning care in such a way as to decrease the transmission of infection to others provides for safety. Plans to increase fluid intake or assist with ADL are pertinent to many clients but are not of highest priority. Deep breathing techniques have no particular relevance in the care of the client with TB.
A nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS) who has Pneumocystis jiroveci pneumonia. In planning infection control for this client, which of the following would be the appropriate form of isolation to use to prevent the spread of infection to others?
Blood and body fluid precautions
A 1-year-old infant is admitted to the hospital for control of tonic-clonic seizures. The nurse helps minimize the infant's risk for injury by:
Removing any toy with bright blinking lights Keeping the sides rails of the child's bed padded Turning the infant on the side during any seizure
A nurse of a well-baby clinic prepares to administer an immunization to a child. The mother of the child tells the nurse that the child has had a fever and is taking antibiotics. The nurse takes the child's temperature and notes that it is 101.5° F rectally. The nurse plans to take which action?
High fevers and severe illnesses are reasons to delay immunization, but only until the child has recovered from the acute stage of the illness. Minor illnesses such as a cold, otitis media, or mild diarrhea without fever are not contraindications to immunization.
