Silvestri Comprehensive Review for the NCLEX-PN® Exam, 7th Edition - Safety Flashcard Set

The nurse is planning to get a client out of bed for the first time after having a total hip arthroplasty (THA). What specific actions would the nurse take? Select all that apply.

- Place a gait belt on the client. - If stretch bands are used, reinforce the correct use. - Observe for any signs/symptoms of dizziness the first time the client gets out of bed. - After the client sits on the side of the bed, remind the client to stand on the unaffected leg.

The nurse is caring for a client who underwent a spinal fusion with a metal implant. The nurse notes that the back dressing is wet with clear drainage. Which actions should the nurse take? Select all that apply.

- Place the client flat in bed. - Notify the registered nurse of the drainage.

The nurse is preparing to suction a client through a tracheostomy tube. The nurse should perform which actions when performing this procedure? Select all that apply.

- Preoxygenating the client before suctioning. - Moistening the catheter tip in sterile saline solution before suctioning. - Introducing the catheter into the tracheostomy tube using a sterile gloved hand.

The nurse is caring for a homebound older postoperative cardiovascular client. The caregiver's daughter says to the nurse, "My mother has fallen out of bed three times." Which actions should the nurse reinforce to prevent falls? Select all that apply.

- Provide adequate lighting. - Ensure that frequently used items are easily accessible. - Have the bedside stand and overbed tray table within reach.

The nurse is assigned to care for a client experiencing episodes of postural hypotension who will be discharged home soon. Which actions should the nurse take to ensure safety while transferring the client from the bed to the chair? Select all that apply.

- Question the client about feelings of dizziness. - Put the client's shoes on to help the client avoid slipping on the floor during the transfer. - Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.

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 implementing which interventions? Select all that apply.

- 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. - Having oxygen and suction available at the bedside.

A client with a diagnosis of tonic-clonic seizures is being admitted to the hospital, and the nurse needs to institute seizure precautions. During a seizure, which items are inappropriate to use and could cause harm to the client? Select all that apply.

- Restraints. - Padded tongue blade.

The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula at 2L. To provide a safe delivery of the oxygen the nurse should avoid which actions? Select all that apply.

- Securing the oxygen tubing to the client's bottom sheet. - Positioning the nasal prongs in the nares and adjusting the plastic slide on the cannula so that the cannula fits as tight as possible.

The nurse assists a primary health care provider (PHCP) with the insertion of a nasogastric tube. Which positions should the nurse place the client in to prepare for the procedure? Select all that apply.

- Slight extension of the neck. - High-Fowler's position.

A client is having trouble remembering his prescribed medication regimen. Which statement by the nurse is therapeutic?

"Let me go over your prescribed medications with you again."

A seriously ill client in the hospital tells the nurse that he thinks he has lost some of his ability to hear over the past few days. The nurse reviews the medications the client is currently receiving. Which medications are known to be ototoxic? Select all that apply.

- Aspirin. - Furosemide - Gentamycin

A client is being discharged to home following spinal laminectomy and fusion with insertion of a metal implant. The nurse includes which instructions about activity after discharge? Select all that apply.

- Avoid activities that involve pulling or pushing. - Do not lift objects weighing more than 5 pounds. - Do not climb stairs until after the follow-up appointment with the surgeon.

The nurse is caring for a client who is receiving an intermittent feeding via a nasogastric (NG) tube. Before feeding the client via the NG tube, the nurse should take which actions? Select all that apply.

- Check the placement of the tube. - Aspirate the contents from the nasogastric tube. - Observe the characteristics and pH of the aspirate from the nasogastric tube.

The nurse is preparing to administer a medication through a nasogastric (NG) tube that is connected to suction. Which interventions should be included to accurately administer the medication? Select all that apply.

- Clamp the NG tube for 30 minutes after medication administration. - Before medication administration, verify correct placement of tube. - Flush the NG tube with saline before and after medication administration. - Discontinue the suction from the tube during administration of medication.

The nurse is preparing to discontinue an indwelling urinary catheter. Which pieces of equipment should the nurse obtain to perform this procedure? Select all that apply.

- Clean towel. - Sterile 10- or 12-mL syringe.

While caring for a client admitted to the hospital with suspected seizure activity, the client acknowledges the use of the herbal supplement ginkgo, to the nurse. Which follow-up questions by the nurse would be most appropriate? Select all that apply.

- Do you have a history of seizures? - Do you have a history of a clotting disorder? How long and why have you been using ginkgo? - Have you been diagnosed with diabetes mellitus?

The nurse is teaching the paraplegic client measures to promote skin integrity. Which instructions would be helpful to the client? Select all that apply.

- Eat a nutritious diet with adequate protein. - Use a pressure relief pad while in a wheelchair. - Check the bottom sheet for wetness and wrinkles.

The nurse is planning to begin a continuous tube feeding on a client with a nasogastric (NG) tube. Which interventions should the nurse perform before initiating the feeding? Select all that apply.

- Explain the procedure to the client. - Irrigate the NG tube with saline. - Elevate the head of the bed to 45 degrees.

The nurse determines that the client has a proper fitting of the crutches when which criteria have been fulfilled? Select all that apply.

- Handgrips are positioned so the elbows are bent approximately 30 degrees. - The space between the axilla and the top of the crutch pad is 1½ to 2 inches. - The nurse can place 3 to 4 fingerbreadths between the axilla and the crutch pad.

The nurse is inquiring about the client's use of complementary and alternative medicines (CAMs). The nurse should be most concerned with the client who uses which CAMs? Select all that apply.

- Homeopathy. - Herbal supplements

The nurse in the hospital is assisting in developing a plan of care for an older client to prevent a fall. Which actions would be least likely to prevent a fall? Select all that apply.

- Keeping the bathroom light off at nighttime. - Placing the client in the quiet area of the nursing unit in a room away from the nurse's station.

The nurse is preparing to administer an intermittent tube feeding to a client with a nasogastric (NG) tube. The nurse checks the residual and obtains an amount of 200 mL. Which actions should the nurse take? Select all that apply.

- Listen to the client's bowel sounds. - Question the client regarding nausea. - Determine whether the client has abdominal distension. - Hold the feeding after flushing the tubing with 30 mL of saline.

A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measures are necessary when caring for this client? Select all that apply.

- Monitoring the skin around the stoma site for skin irritation. - Administering intermittent feeding through a 60-mL syringe with the plunger removed and the barrel attached to the gastrostomy tube.

The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care to a client. Which instructions should be included in the list? Select all that apply

- Obtain a Medic-Alert bracelet. - Prevent debris from entering the stoma. - Avoid exposure to people with infections. - Avoid swimming and use care when showering.

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 data specifically associated with this therapy before the initiation of therapy? Select all that apply.

- Pedal pulses. - Capillary refill. - Color of the extremity. - Temperature of the skin. - Presence of numbness.

The nurse is caring for a child following a cleft palate repair who has elbow 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 restraints

The nurse is working in a long-term care facility and is observing a new unlicensed assistive personnel (UAP) caring for a client who requires a security device (wrist restraints). The nurse determines that the UAP is providing safe care if the nurse observes the UAP checking skin integrity by completely removing the client's wrist restraints at which time interval?

Every 2 hours.

The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the intravenous (IV) of an assigned client who is receiving fluid replacement therapy how frequently?

Every hour.

The nurse is reinforcing instructions to the unlicensed assistive personnel (UAP) who will be caring for a client with security devices (hand restraints). How often should the nurse instruct the UAP to check the client's skin and circulation under the security devices?

Every thirty minutes.

An adolescent client is admitted to the hospital following an accidental gunshot wound to the foot. The nurse should plan to do which as a first step for the prevention of future injury?

Explore the adolescent's knowledge of gun safety.

A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed linens changed. Which should the nurse wear to perform these tasks?

Gown and gloves

The nurse is preparing to administer an acetaminophen suppository to a child. The nurse plans which action?

Insert the suppository 1 to 2 cm into the rectum.

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 is the nurse's priority for client care?

Institute contact precautions.

The 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 avoid medication errors.

The 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 primary health care provider is aware of all of the medications the client is taking and has been taking at home.

The nurse is reinforcing instructions to a client about safety measures while using oxygen in the home. The nurse determines that there is a need for further teaching if the client verbalized which statement?

Keep the oxygen concentrator as close to the room wall as possible.

The nurse is preparing to apply a mitten restraint to the client's hand. The nurse does which to ensure that the restraint is applied correctly? Refer to video. Click on the Question Video button to view a video showing preparation procedures.

Makes sure that two fingers can be inserted under the restraint.

A licensed practical nurse (LPN) asks an unlicensed assistive personnel (UAP) to gather supplies in preparation for administering a tepid bath to a child with an elevated temperature. The LPN intervenes if the UAP obtains which unnecessary item(s)?

A bottle of alcohol.

Which client is the safest one for a licensed practical nurse (LPN) to care for?

A client recovering from a scheduled cesarean delivery.

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 monitoring the laboratory results of a female client receiving an antineoplastic medication by the intravenous (IV) route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?

A platelet count of 40,000 mm3 (40 × 109/L).

During a fire drill, the nurse enters a laundry room and a waste basket is marked as on "fire." The nurse activates the alarm, closes the laundry room door, and obtains a fire extinguisher and returns to the laundry room. Which action by the nurse shows that additional training is needed?

Aiming at the top flames of the flame.

The 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?

Alternating air pad.

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 is preparing to feed a client who is at risk for aspiration. The nurse assesses the client and uses a penlight and tongue blade to check the mouth and cheeks for pockets of food. Which action does the nurse take next? Refer to video. Click on the Question Video button to view a video showing preparation procedures.

Places the client in an upright position.

A client who is recovering from a brain attack (stroke) has residual dysphagia and is prescribed nectar thickened liquids. The licensed practical nurse has instructed the unlicensed assistive personnel (UAP) in feeding technique. The nurse should intervene if the UAP attempts to perform which activity?

Placing food on the affected side of the mouth.

A primary health care provider writes a prescription to apply a heating pad to a client's back. The nurse implements the prescription and avoids which action?

Placing the heating pad under the client.

The nurse administers an injection to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). After administering the medication, the nurse should dispose of the used needle by which method?

Placing the needle and syringe in a puncture-resistant container.

The nurse is instructing a group of unlicensed assistive personnel (UAP) in the principles of body mechanics. The nurse determines that a student is using the principles appropriately if the nurse observes the UAP doing which action?

Positioning a box that is to be lifted between the knees.

The nurse is assigned to assist in caring for a client who has had surgery and has pneumatic sequential compression devices (SCDs) in place. The client asks about these devices. The nurse instructs the client that SCDs are used for which purpose?

Promoting venous return to the heart.

The nurse is reinforcing instructions provided to a client with a continuous passive motion (CPM) machine. The nurse determines that there is a need for further teaching when the client states that he should perform which action?

Reset the degrees of flexion or extension according to comfort.

The nurse reinforces instructions to the parents of a newborn infant regarding car travel and safety seats. Which information related to the safety of the infant is correct?

Restrain in a car seat in the back seat in a semi-reclined, rear-facing position.

The nurse assists in conducting a home safety assessment with a client preparing for discharge. The client tells the nurse that a space heater is used to heat part of the apartment. Which instruction 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.

The nurse is caring for a hospitalized older client who has pulled out his IV for the second time. The nurse inserts a new IV. Which intervention should the nurse institute next for the client?

Wrap a light roll of gauze to cover the IV site.

The nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further teaching?

"I need to be sure to place my cup of coffee on the counter."

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 mother tells the pediatrician's office nurse that she is concerned because her children must let themselves into the house after school each day while she is at work and they feel isolated and fearful. The nurse should suggest which to the mother?

"You should seek community after-school programs or activities for your children."

The nurse is reinforcing instructions about home safety measures regarding medications and toxic substances to a parent. Which parent statements indicate a need for further teaching? Select all that apply.

- "I need to refer to medication as 'candy' only when really necessary." - "I can place several medications in the same bottle if I am going for an overnight trip."

The nurse is assisting in preparing a client for discharge to home. Daily cold therapy has been prescribed for the client, and the nurse reinforces instructions about this treatment. Which client statements indicate adequate understanding of cold therapy treatment? Select all that apply.

- "I will remove the ice pack if I start to feel numbness." - "I should wrap the frozen ice pack in a towel to help adjust to the cold."

The nurse initiates a prescription from the primary health care provider and restrains a client who has a chest tube connected to suction. The client is confused and continues to remove the dressing around the tube and pulls at the tube. Which information should the nurse document in the client's medical record regarding restraints? Select all that apply.

- Adequacy of circulation in the body area that is restrained. - Type of restraint and body area where the restraint was applied. - Communication with client and family member about need for restraint. - The alternative measures that were attempted before restraints were applied.

The 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 in the plan of care? Select all that apply.

- Allowing the client sufficient time to eat. - Providing oral hygiene after each meal. - Maintaining a suction machine at the bedside.

The nurse is caring for a client who becomes agitated and begins to pull on a surgically placed abdominal drainage tube. The primary health care provider visits and prescribes restraints if needed. Which actions are appropriate to delegate to the unlicensed assistive personnel (UAP), who has completed the facility's education about care of the restrained client? Select all that apply.

- Socialize with the restrained client. - Remove the restraint and perform range of motion activity. - Reapply the restraint after assisting the client to the bathroom.

The nurse reviews the laboratory values on a child with leukemia receiving chemotherapy. The nurse notes that the platelet count is 19,000 mm3 (19 × 109/L).Based on this laboratory result, which actions should the nurse include in the plan of care? Select all that apply.

- Testing stools and urine for blood. - Using a soft toothbrush for mouth care.

The nurse is assigned to care for a client who has a nasogastric (NG) tube and is receiving tube feedings. When implementing nursing care for the client, the nurse remembers which information? Select all that apply.

- That aspiration as a complication is a primary concern. - To determine correct placement by aspirating contents from the tube to observe characteristics and check pH.

The nurse is assigned to the care of a client who is being admitted to a facility. The nurse notes which observations as indications the client likely has a hearing deficit? Select all that apply.

- The client answers questions incorrectly. - The client states she quit attending social events. - The client does not respond to a person unless facing the speaker.

The nurse considers the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery. Which are correct about this protocol? Select all that apply

- The surgeon is the person that marks the area of the operative procedure. - The site marking is done before the client is brought to the surgical suite in the operating room.

The nurse admits a client who has seizure precautions prescribed. The client has a seizure just after the nurse has implemented the precautions. Which actions should the nurse take? Select all that apply.

- Time the start and stop of the seizure. - Apply oxygen at 2L with nasal cannula. - Turn the client to the side and do not restrain. - Note the distinguishing characteristics of the seizure. - Turn on the suction machine with oral catheter.

The nurse is caring for an older client who had surgery to repair a fractured hip. In the late evening the client becomes slightly confused and is moving about in bed. Which actions should the nurse take initially? Select all that apply.

- Turn on the bed alarm. - Ask the client about needing to void or move bowels. - Turn on the nightlight in the hospital room and bathroom.

The nurse is performing an environmental assessment in the home of an older client. Which observations require immediate attention? Select all that apply.

- Unsecured scatter rugs. - Cigarette pack and lighter on the bedside stand.

The nurse is preparing to reposition a dependent client who weighs more than 250 lbs. Which interventions should the nurse use to move this client? Select all that apply.

- Use a friction-reducing slide sheet - Use a mechanical lift to move the client. - Keep elbows close and work close to the body. - Obtain assistance of a second caregiver to assist with the mechanical aids.

The nurse is administering mouth care to an unconscious client. The nurse should avoid doing which actions? Select all that apply.

- Using products with lemon or alcohol. - Positioning the client supine.

The nurse is assisting in the care of a client diagnosed with acquired immunodeficiency syndrome (AIDS) who requires an injection. The nurse should include which actions to safely administer the medication? Select all that apply.

- Wear gloves while administering the injected medication. - Dispose of the needle and syringe in a puncture-resistant container.

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.

A client is transferred from the special care unit to the medical-surgical unit. The nurse receives report and plans to calculate the fall risk. The client is a male, aged 61, admitted to the hospital after being injured in a motor vehicle crash. He has no history of falling. He has no vision or hearing deficits. He has a peripheral continuous intravenous infusion, an indwelling urinary catheter, and sequential compression devices (SCD) while in bed. His gait is steady. He needs supervision when ambulating and uses the call light to contact the nurse for assistance. His prescribed medications include furosemide, penicillin, and ibuprofen. He has received ibuprofen twice in the last 24 hours. He is oriented and cooperative. Which score should the client receive based on the fall risk tool? Refer to figure.

9 total points (moderate risk).

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 is told that a client will be admitted to the hospital for a radiation implant. The nurse is asked to prepare for the admission of the client and plans which measure for this client?

Admit the client to a private room.

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 is reinforcing instructions to a client with chronic vertigo that is poorly controlled. The nurse stresses the importance of which safety measure to prevent injury or exacerbation of symptoms?

Removing throw rugs and clutter in the home.

The nurse is preparing to clean up a blood spill on the client's bedside table. The spill occurred when a blood tube containing the client's blood specimen broke. The nurse avoids doing which action when cleaning up the blood spill?

Blotting up the spill with a face cloth or cloth towel.

A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing?

Closes the roller clamp on the IV tubing.

The nurse is preparing to initiate a tube feeding for a client and the primary health care provider has prescribed that the feeding be infused at 50 mL per hour. The nurse brings an electronic feeding pump to the bedside and discovers that there is no available outlet in the wall socket to plug the pump into. Which action should the nurse implement?

Contact the electrical maintenance department for assistance.

The nurse is assigned to care for a client with a peripheral intravenous (IV) infusion. The nurse is providing hygiene care to the client and should avoid which while changing the client's hospital gown?

Disconnecting the IV tubing from the catheter in the vein.

The nurse prepares to administer a prescribed dose of scopolamine. The nurse should monitor for which side effect of this medication?

Dry mouth.

The nurse employed in the ambulatory care department hears a client in the waiting room call out, "Help, fire!" The nurse rushes to the waiting room and finds the wastebasket on fire. Which is the immediate action of the nurse?

Remove the clients from the waiting room.

The nurse enters the room to find that the client's trash can is in flames. The client is in bed and the edge of the gown is smoking. The nurse should take which action first?

Remove the gown from the client and remove the client from the room.

The nurse is changing the neck ties on a tracheostomy tube. Which method is appropriate for the nurse to take?

Remove the old ties, clean the site, and then apply the new ties while a second health care team member holds the tracheostomy tube.

A client with chronic pain has been taught how to operate a transcutaneous electrical nerve stimulation (TENS) unit. Which client action shows understanding of the appropriate use of the device when the level of stimulation is uncomfortable?

The client adjusts the setting downward slightly.

The nurse is assisting a client to ambulate when the client states he is feeling faint and cannot stand. Which action should the nurse take to assist the client now?

The nurse should extend one leg to use to slide the client's body down to the floor.

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.

The registered nurse (RN) and a licensed practical nurse (LPN) are discussing total parenteral nutrition (TPN) with a client who is receiving TPN through a peripherally inserted central catheter (PICC). The client asks why the solution is being infused through a central catheter IV. The nurses explain that TPN is preferably infused through a central line for which reason?

There is greater blood flow with a central line IV to dilute the TPN, which is a concentrated solution and needs to be diluted to avoid damage to the blood vessel.

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.