Saunders

The nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the child and the prevention of the transmission of the virus. Which statement by a parent indicates a need for further teaching?

"I need to provide a well-balanced, high-fat diet to my child."

The nurse reinforces instructions to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the need for further teaching?

"I need to take my child's rectal temperature daily."

The nurse is reinforcing home-care instructions to the parents of a 3-year-old child with scabies. Which statement by a parent indicates the need for further teaching?

"I understand that I need to leave the scabicide on for 4 hours before washing it off."

The nurse reinforces home care instructions to the parents of a 3-year-old child who has been hospitalized with hemophilia. Which statement by a parent indicates the need for further teaching?

"I will avoid immunizations and dental hygiene treatments for my child."

A pregnant human immunodeficiency virus (HIV)-positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. Which statement by the woman indicates that additional guidance is needed?

"I will breastfeed, especially for the first 6 weeks postpartum."

The nurse is providing discharge instructions to the parents of a 14-year-old child who is undergoing radiation for Hodgkin's disease. Which statement by a parent indicates the need for further teaching?

"I will need to keep my child's skin from flaking, so we will be allowing showers every 2 or 3 days."

The nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further teaching?

"I will place a steam vaporizer in my child's bedroom."

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply.

"Mass casualty events do not require an increase in the number of staff that are needed." "Mass casualty events do not require an increase in the number of staff that are needed." "A mass casualty event occurs if a fight between visitors occurs in the emergency department."

The nurse is reinforcing discharge instructions to the parents of a 2-year-old child who sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have correctly understood the teaching when they make which statement?

"We will be sure not to leave hot liquids unattended."

A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which information to the client?

"You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed."

The nurse is talking to a pregnant client with human immunodeficiency virus (HIV) infection regarding care for the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?

"You will need to bottle-feed your newborn."

The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)?

A client who requires frequent ambulation

The nurse is caring for a group of clients who are taking herbal medications at home. Which client should be given instructions with regard to avoiding the use of herbal medications?

A 10-year-old female client with a urinary tract infection

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse collect data from first?

A client receiving oxygen who is having difficulty breathing

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first?

A client who is dependent on a ventilator

The nurse employed in a long-term care facility is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)?

A client who requires a 24-hour urine collection

The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client?

A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

The nurse finds the client lying on the floor. The nurse calls the registered nurse, who checks the client and then calls the nursing supervisor and the primary health care provider to inform them of the occurrence. The nurse completes the incident report for which purpose?

A method of promoting quality care and risk management

The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside?

A pair of scissors

The nurse is caring for an 18-month-old child who has been vomiting. Which is the appropriate position to place the child during naps and sleep time?

A side-lying position

When caring for a 3-year-old child, the nurse should provide which toy for the child?

A wagon

The 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 should be the initial nursing action?

Activate the agency emergency response plan.

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse quickly assists the client out of the room. Which is the next nursing action?

Activate the fire alarm.

The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. Which is the next action the nurse should perform?

Aim at the base of the fire.

The nurse should plan which to encourage autonomy in the client who is a resident in a long-term care facility?

Allowing the client to choose social activities

A licensed practical nurse (LPN) attends a session about bioterrorism agents including anthrax. Which statement by an attendee demonstrates the need for further teaching about anthrax?

Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis.

The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included?

As-needed medications given that shift

A client experiences cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style?

Autocratic

The nurse is preparing an intravenous (IV) solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse should plan to take which action?

Change the IV tubing.

A child is brought to the emergency room and the mother reports that the child accidentally swallowed paint thinner after mistaking it for water. The nurse should perform which action first?

Check the circulation, airway, and breathing status of the child.

The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action?

Decline to sign the will.

The licensed practical nurse (LPN) enters a client's room and finds the client lying on the bathroom floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and primary health care provider (PHCP) are notified of the incident. Which is the next nursing action regarding the incident?

Document a complete entry in the client's record concerning the incident.

The nurse caring for a child with aplastic anemia is reviewing the laboratory results and notes a white blood cell (WBC) count of 6000 mm3 (6 × 109/L) and a platelet count of 20,000 mm3 (20 × 109/L). Which nursing intervention should be incorporated into the plan of care?

Encourage quiet play activities.

The nurse is assigned to assist with caring for a neonate born to a mother who is human immunodeficiency virus (HIV)-positive. The nurse understands that which should be included in the plan of care?

Maintaining standard precautions at all times while caring for the neonate

The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? Select all that apply.

Monitor the skin temperature closely. Reposition the newborn every 2 hours. Cover the newborn's eyes with shields or patches.

The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which describes the team-based model of nursing practice?

Nursing staff are led by the nurse when providing care to a group of clients.

A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The nurse reviews the plan of care and should question which intervention that is written in the plan?

Palpate the abdomen for a mass.

The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of tasks?

Perform follow-up with each staff member regarding the performance and outcome of the task.

The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric tube. How should the nurse determine that the restraints are not too constrictive?

Place two fingers under the restraint to determine snugness.

The nurse administers erythromycin ointment (0.5%) to the newborn's eyes and the mother asks the nurse why this is done. The nurse should give which response to the client?

Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection

The nurse is caring for a client with a health care associated infection caused by methicillin-resistant Staphylococcus aureus. Contact precautions are prescribed for the client. The nurse prepares to irrigate the wound and apply a new dressing. Which protective interventions should the nurse use to perform this procedure? Select all that apply.

Put on a mask. Don gown and gloves. Wear a pair of protective goggles.

The nurse observes that a client received pain medication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed this same occurrence several times. Based on the nurse practice act, the observing nurse should plan to take which action?

Report the information to a nursing supervisor.

The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action?

Report to the pediatric unit and identify tasks that can be safely performed.

The 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 should be included in the list? Select all that apply.

Siblings may also need treatment. Grooming items such as combs and brushes should not be shared. Launder all the bedding and clothing in hot water and dry on high heat. Vacuum floors, play areas, and furniture to remove any hairs that may carry live nits.

The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item?

Sterile 2 × 2 gauze

The nurse is reviewing the postoperative primary health care provider's (PHCP'S) prescriptions for a 3-week-old infant with Hirschsprung's disease admitted to the hospital for surgery. Which prescriptions documented in the child's record should the nurse question? Select all that apply.

Take temperature measurements rectally. Start clear liquid diet after 8 hours postoperative.

A licensed practical nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching?

Taking an oral temperature for a client with a cough and nasal congestion

A nurse lawyer provides an education session to the nursing staff regarding client rights with emphasis on invasion of client rights. The nurse lawyer asks a staff nurse to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?

Taking photographs of the client without consent

Which identifies accurate nursing documentation notations? Select all that apply.

The client slept through the night. Abdominal wound dressing is dry and intact without drainage. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

The nurse obtains a prescription to restrain a client using a belt (safety) restraint and instructs the unlicensed assistive personnel (UAP) to apply the restraint. Which observation, if made by the nurse, indicates unsafe application of the restraint?

The restraint straps are safely secured to the side rails.

An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action?

Transport the client to the operating department immediately without obtaining an informed consent.

The nurse is planning to feed an older client who is at risk for aspiration of food. During the meal how should the nurse position the client?

Upright in a chair

The nurse should institute which interventions for a client diagnosed with Clostridium difficile? Select all that apply.

Wear gloves and gown while in the room caring for the client. Use soap and water, not alcohol-based hand rub, for hand hygiene.

The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply.

Wearing gloves when emptying the client's bedpan Keeping all linens in the room until the implant is removed Wearing a film (dosimeter) badge when in the client's room Wearing a lead apron when providing direct care to the client