Unit 5- Safety and Infection Control

A nurse is preparing a client for cardiac catheterization. What is the nurse's priority assessment?

Known allergies Since cardiac catheterization involves the injection of a radiopaque dye. It is most important for the nurse to determine if this client has allergies to iodine or shellfish. The other three parameters are also part of the assessment, but are not the priority.

The nurse is to apply a sequential compression device (intermittent pneumatic compression). Identify the area of the compression device that is placed on the client's calf.

The air cell should be centered on the back of the client's calf.

A water-soluble biohazardous bag is placed in the room of a client in contact precautions. Which item should the nurse place into this bag?

linens A water-soluble bag should be used for items that are dry but when the bag is placed in hot water it dissolves. Linens should be placed in the water-soluble bag for cleaning. Food wrappers and containers can be placed in the regular trash. A water pitcher and intravenous fluid would cause the water-soluble bag to disintegrate.

X-rays reveal a leg fracture in a client who was brought to the emergency department after falling on ice. After a cast is applied and allowed to dry, the nurse teaches the client how to use crutches. Which instruction should the nurse provide about climbing stairs?

"Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together." When climbing stairs with crutches, the client should lead with the unaffected leg, followed by the crutches and injured leg moving together. Any other method is incorrect and could increase the client's risk of falling.

Upon initial assessment of a postoperative client, the nurse identifies that the I.V. infusion is different from the solution ordered by the physician. What is the first action the nurse should take?

Assess the client, call the physician, and then hang the ordered solution. This scenario is the same as any medication error. The client must be assessed, the physician must be notified, and the correct solution should be given to the client. The other answers are incorrect because they do not ensure that the client will receive appropriate follow-up care for a medication error.

A nurse practitioner (NP) orders an antibiotic to which the client is allergic. The nurse preparing the medication notices the allergy alert and contacts the NP by phone. The NP does not return the call and the first dose is due to be given. Which action by the nurse is the best solution?

Hold the medication until speaking with the NP. The nurse must speak to the NP and review the order. The other answers are incorrect because the nurse is aware of a stated allergy and must not give a medication that can cause an allergic reaction. The pharmacist cannot prescribe a new medication.

An infant goes into cardiac arrest. While conducting resuscitation, the team notes critical supplies are missing because the cart was not restocked properly by the nurses after an earlier arrest. The baby sustains brain damage as a result of delays in obtaining needed supplies. How does the nurse manager address this situation?

Hold the nurses responsible because hospital procedure was not followed. Agency and hospital policies and procedures establish standards of care. If a nurse deviates from the standard, liability could result if an injury is sustained. In this case, the baby sustained brain damage because the nurses failed to follow the procedure for restocking the crash cart immediately after a code. The nurse needs to report to the pharmacy that the medications need to be restocked. The pharmacist cannot be blamed or held liable if they were not notified. The manager should not tell the nurses they will not be held liable. There is not evidence that current practice needs to be changed, just followed consistently.

A client is admitted to the emergency department with a closed head injury after being found unconscious. Based on information from the client's neighbor, the staff suspects intimate partner violence. The client has a restraining order against the spouse, but the spouse repeatedly attempts to visit the client. Which action should the nurse take?

Inform hospital security personnel of the restraining order and description of spouse. The nurse should inform hospital security personnel about the restraining order and formulate an action plan with security that protects the client. The nurse does not have the authority to assign security personnel to be at the client's bedside. Measures should be in place to stop the spouse before he enters the unit, and a sign on the client's door could actually alert the spouse to the client's location. Admitting the client under an assumed name would require the client's consent and additional supervisor approval.

Which activity should a nurse recommend to prevent foreign body aspiration in a child during meals?

Insist that the child remain seated while eating. A child should remain seated while eating. The risk of aspiration increases if the child is running, jumping, or talking with food in his mouth. Television and toys are a dangerous distraction to toddlers and young children and should be avoided during meals. A child needs constant supervision and should be monitored while eating snacks and meals.

A client from a correctional facility is admitted to the hospital wearing handcuffs. The nurse caring for the client needs to provide morning care and notices the two correctional officers socializing with the nursing staff at the desk. What is the best action by the nurse in this situation?

Insist that the officers stay in the room at all times. A correctional officer should be with the client at all times. To protect the safety of the nurse and the client, the nurse should refuse to administer care without an officer present. The other options put the nurse and the client at risk.

A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, what should the nurse do first?

Institute droplet precautions. The child with meningococcal meningitis requires droplet precautions for at least the first 24 hours after effective therapy is initiated to reduce the risk of transmission to others on the unit. After the child has been placed on droplet precautions, other actions, such as taking the child's vital signs, asking about medication allergies, and inquiring about the health of siblings at home, can be performed.

A nurse is scheduled to perform an initial home visit to a new client who is beginning home intravenous therapy. As the nurse is getting out of the car and beginning to approach the client's building, a group of people begin following and jeering at the nurse. Which is the nurse's best response to this situation?

Leave the area in the car, provided the nurse can get to it safely. The nurse's safety is paramount, and the nurse's best response to a perceived threat when performing a home visit is to remove themself from the situation, provided this can be achieved without incurring further risk.

The nurse changes a client's dressing and disposes of the used items into a biohazardous waste receptacle. Which is the best action for the nurse to take if the biohazardous bag begins to leak fluid?

Place the leaking bag into another biohazardous bag. Double-bagging may be required if the single bag is not secure or is soiled on the outside. A leaking bag should be double-bagged. It is not sufficient to place absorbent pads under the leaking bag. The leaking bag will continue to seep contaminants if it is placed outside the client's room. The biohazardous bag should not be placed in the bathroom sink.

As the nurse arrives to visit a family 2 days after release from the hospital, she hears shouting and swearing between the mother and father and several loud crashes, just as she is going to knock on the door. What action by the nurse is the most appropriate?

Return to the car and call the police. The nurse needs to consider his/her own personal safety in this situation and how he/she will be the most help to this family. The nurse needs to get some back-up support before entering the house due to the potential for violence. The nurse should not go into the home if his/her safety is in danger.

The pediatric nurse is providing care for an infant who has been diagnosed with respiratory syncytial virus (RSV). What action best prevents the spread of this infectious microorganism?

Wear a face mask when in close contact with the client. RSV infection necessitates droplet precautions, including the use of a facemask. Goggles are not normally included in droplet precautions. It is important to educate family members and visitors about the need for hand hygiene, but the similarities and differences between the two different methods of performing hand hygiene are not a priority. Antiviral medications such as ribavirin are not commonly used, and they do not directly prevent the spread of the infection.

When developing a seminar on injury prevention to be presented to a group of parents of children from 2 to 18 years, the nurse should place priority on discussing the use of which measure?

child restraints in automobiles Motor vehicle injuries are a leading cause of death in children older than 1 year of age. Most fatalities are related to nonuse of child restraints and seat belts.Although using helmets for biking and skating safety is important, it is not the priority.Special locks for cabinets are important in the prevention of poisoning for children of some ages, but this is not the priority.Topical bug repellent in summer is important for the prevention of Lyme disease. However, this is not the priority.

Which nursing intervention is most important in preventing septic shock?

maintaining asepsis of indwelling urinary catheters Maintaining asepsis of indwelling urinary catheters is essential to prevent infection. Preventing septic shock is a major focus of nursing care because the mortality rate for septic shock is as high as 90% in some populations. Very young and elderly clients (those younger than age 2 or older than age 65) are at increased risk for septic shock. Administering IV fluid replacement therapy, obtaining vital signs every 4 hours on all clients, and monitoring red blood cell counts for elevation do not pertain to septic shock prevention.

A parent of a 9-year-old-child scheduled to have surgery expresses concern about the potential for postoperative infection. A nurse provides the parent with information about the measures taken to maintain surgical asepsis. Typical surgical asepsis involves:

performing a preoperative surgical scrub for at least 3 to 5 minutes. The surgical team should perform a surgical scrub lasting at least 3 to 5 minutes before any operative procedure. Although surgical gowns may be considered sterile, surgical scrubs are considered clean rather than sterile. Jewelry harbors bacteria; team members should remove it rather than simply clean it. A surgical team member with an open wound shouldn't be involved in a procedure requiring asepsis.

A client, diagnosed with active tuberculosis (TB), asks the nurse if they will be admitted to the hospital. The nurse responds that hospitalization would most likely occur to

prevent the spread of the disease. A client with active TB is highly contagious until three consecutive sputum cultures are negative. This client should be put on respiratory isolation in a hospital setting.

Over the past few weeks, a client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure does not comply with a least restraint policy?

raising all side rails while the client is in bed Raising all side rails on the bed would be a restraint and may increase the client's risk of a falling if the client climbs out of bed. All the other options would comply with a least restraint policy.

The nurse understands that the client who is undergoing induction therapy for leukemia needs additional instruction when the client makes which statement?

"I cannot wait to get home to my cat!" The nurse identifies that the client does not understand that contact with animals must be avoided because they carry infection and the induction therapy will destroy the client's white blood cells (WBCs). The induction therapy will cause anemia, and the client will experience fatigue and will have to pace activities with rest periods. Platelet production will be decreased, and the client will be at risk for bleeding tendencies; oral hygiene will have to be provided by using a warm saline gargle instead of brushing the teeth and gums. The client will be at risk for infection owing to the decrease in WBC production and should report a temperature of 100° F (37.8° C) or higher.

A client with schizophrenia, who has a history of being placed in seclusion for physically assaulting other clients, is showing signs of increased agitation. The client causing self-harm with fingernails to the face and eyes. All nursing attempts to reduce this behavior have failed. What should the nurse do next?

Apply physical restraints to protect the client, then contact the physician for orders. A nurse may place a client in physical restraints if the client poses a threat to self or others and all less-restrictive interventions have failed. A nurse may place a client in restraints without a physician's order but must obtain an order within 1 hour of restraint application. Secluding the client, with or without security involvement, doesn't protect the client from injury.

A public health nurse has been asked to teach the importance of hand washing to elderly clients. Which statement by a client indicates that the teaching has been effective?

Friction while washing hands decreases transmission of bacteria. Soap helps by reducing surface tension of water, but friction is necessary for the removal of microorganisms. The use of warm water still needs friction. Use of other products besides soap can reduce infection. Fifteen seconds is an insufficient length of time for hand washing.

A nurse is teaching a parent of a toddler diagnosed with conjunctivitis to administer the ophthalmic ointment. Which action by the mother indicates that further instruction is necessary?

The mother holds the eyelids open with her fingers. Washing hands before and after administration to an infected eye is very important to prevent the spread of conjunctivitis. Applying the ointment to the lower conjunctival sac ensures the medication will adequately cover the eye. Cleaning the eye prior to administration helps the medication be absorbed and decreases the bacteria in the eye. Holding the eyelids open will not allow application of the medication to the lower conjunctival sac.

An adolescent client is having surgery to repair a fractured left femur. As a part of the preoperative safety checklist, what should the nurse do?

Verify that the site, side, and level are marked. As part of a surgery safety checklist, the nurse must verify that the site, side, and level are marked. Pointing to the area is not sufficient identification of the surgery site. The nurse must verify the form has been signed by reviewing the form. The surgeon holds primary responsibility for explaining the risks of surgery.

While administering medication, the client tells the nurse, "I've never seen this pill before." The nurse should:

check the medication orders. When a client indicates that something looks different, the nurse should verify the medication before assuming it is correct.

A toddler receiving chemotherapy after surgery for a Wilms' tumor has developed neutropenia. The parent is trying to encourage the child to eat by bringing extra foods to the room. Which food would the nurse discourage for this child?

fresh strawberries When a client receiving chemotherapy develops neutropenia, eating uncooked fruits and vegetables may pose a health risk due to possible bacterial contamination. All other foods are either cooked or pasteurized and would not produce a health risk.

A nurse is caring for a client with watery diarrhea and dehydration. Given the client's recent history of heavy antibiotic use, what interventions should the nurse consider?

wearing gown and gloves when working in the room The client presents with the risk factors and symptoms of Clostridium difficile diarrhea, which requires contact isolation. Changing diet or giving anti-diarrhea medications will not improve the situation; specific antibiotics are effective in most cases. It is important to encourage fluids but I.V. would be preferred since oral fluids are expelled in the stool.

The nurse is administering oxycodone for leg pain, as requested by the client. What priority actions will the nurse implement? Select all that apply.

Verify the healthcare provider's order. Assess the client for allergies. Assess the client's respirations. Identify the client. The nurse will verify the order, assess for allergies, and identify the client for safe medication administration. The nurse needs to assess the client's respiratory system because oxycodone can cause respiratory depression. The nurse does not have to assess the client's activity level for the pain medication administration.

A nurse-manager is auditing the nursing unit's adherence to infection-control practices. Which observation causes the nurse-manager to be most concerned that the clients on the unit are at risk for infection?

A nurse does not wear a gown when caring for a client on contact precautions. To minimize the spread of infection a nurse must follow appropriate isolation practices. A gown would be worn when caring for a client on contact precautions. A mask is not necessary for clients on standard precautions, and sterile gloves are not required for I.V. insertion. Although administering the antibiotic late is cause for concern, it does not present as big a risk as failure to follow appropriate isolation practices.

A staff nurse receives a phone call and is told there is a bomb in a client's room. What is the nurse's priority action?

Ask the caller for details about the bomb placement. With imminent danger, it is important to determine as much information as possible, as quickly as possible. Transferring the call, or placing the caller on hold could result in a disconnection and loss of information. Clients may need to be evacuated.

When assessing an elderly client, a nurse on the day shift notes redness in the sacral region. Close assessment reveals small breaks in the skin surface. The client says the area is tender and must have lost skin when a nursing assistant on the previous shift moved the client. The client tells the nurse, "The nursing assistant on the last shift was rough. I asked the nursing assitant to look at my backside, but the nursing assistant said they were too busy." What should the nurse do first?

Document the findings. The nurse must first document the assessment findings; timely documentation helps ensure accuracy. The nurse should notify the shift supervisor after completing the documentation. The nurse must follow the chain of command. The nurse isn't a manager or supervisor and may not have the authority to administer discipline. Although it might be appropriate for the nurse to make an incident report, the nurse doesn't yet have adequate information to prepare a complete report.

Indicate on the illustration where the nurse would place the other electrode of the automated external defibrillator on a victim who has collapsed and does not have a pulse.

One electrode is placed to the right of the upper sternum just below the right clavicle. The other is placed, as shown, over the fifth or sixth intercostal space at the left anterior axillary line.

Which instruction should the nurse expect to include in the discharge teaching plan for the parent of an infant who has had an inguinal herniorrhaphy?

Change diapers as soon as they become soiled. Changing a diaper as soon as it becomes soiled helps prevent wound infection, the most common complication after inguinal hernia repair in an infant secondary to possible wound contamination with urine and stool. Because the surgical wound is unlikely to separate, an abdominal binder is unnecessary. The incision may or may not be covered with a dressing. If a dressing is not used, the health care provider (HCP may apply a topical spray to protect the wound. Restraining the infant's hands is unnecessary if the diaper is applied snugly. The infant would be unable to get the hands into the diaper close to the surgical site.

A nurse working in the emergency department is concerned that a client, who is in police custody, is handcuffed to the stretcher. The nurse asks the police officer to remove the cuffs, but the officer refuses. What should be the next action by the nurse?

Continue to assess the client, allowing the officer to assume responsibility for the handcuffs. In this situation, the police officer has applied the restraint and has taken responsibility for the restraint. The nurse should assess the client for any potential complication from the handcuffs, document the assessment, and provide care to the client as usual. The other options are incorrect because the police officer has assumed responsibility for the restraint. It is unlikely that a physician would order the restraint to be removed against the officer's recommendation, and if the restraints are in place and the officer is present, the nurse can provide care to the client.

A client in surgery has an endotracheal tube (ET) in place. The nurse should call a time-out if which requirements are not in place? Select all that apply.

an identification band an IV line oxygen administration an anesthetist/anesthesiologist The nurse is responsible for the client's safety in the operating room. The nurse should call a time-out if the client is not properly identified with an identification band. In addition, an IV line and oxygen should always be established when an ET tube is placed. This practice applies whenever a client's airway is compromised enough for intubation to occur, not only in the operating room environment. An anesthetist or anesthesiologist should be present during surgery to manage the airway. Postoperative pain medication is administered in the recovery room.

The nurse-manager of a 20-bed coronary care unit is not on duty when a staff nurse makes a serious medication error that results in a client's overdose. The client nearly dies. Which statement accurately reflects the accountability of the nurse-manager?

The nurse-manager would receive a call at home from the on-duty nursing supervisor, apprising the nurse-manager of the problem as soon as possible. The nurse-manager is accountable for what happens on the unit 24 hours per day, 7 days per week. If a serious problem occurs, the nurse-manager should be notified as soon as possible. None of the other choices accurately reflect the nurse--manager's accountability in this situation.

An HIV-positive client discovers that their name is published in a report on HIV care prepared by the nurse. The client strongly opposes this and files a lawsuit against the nurse. Which offense has this nurse committed?

invasion of privacy The nurse has committed the tort of invasion of privacy. Personal names and identities are concealed or obliterated in case studies or research work. Invasion of privacy is a type of intentional tort. Defamation is an act in which untrue information harms a person's reputation, and is therefore not applicable here. Negligence is the harm that results because a person did not act reasonably.

A nurse administers incorrect medication to a client. After assessing the client, and completing an incident report, which is the priority action by the nurse?

Report the incident to risk management. The incident should be reported to risk management in order to evaluate care, and determine potential risks or system problems that contributed to the error. This type of error will not be reported to the nursing regulatory agency, or result in the nurse's suspension. Some facilities track the number of errors made by a nurse, or that occur on a particular unit, in order to provide appropriate education, and to improve the nursing process. Adverse drug reaction forms are used to report a client's reaction to a medication, not errors.

A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client?

an isolation room three doors from the nurses' station A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease.

A nurse is teaching the parents of a young child how to handle suspected poisoning. If the child ingests poison, the parents should first

call the poison control center. Before intervening in any way, the parents should first call the poison control center for specific instructions. Ipecac syrup is no longer recommended for the ingestion of poisons. The parents may have to call an ambulance after calling the poison control center. Punishment for being bad isn't appropriate because the parents are responsible for making the environment safe.

An infant is admitted to the hospital with dehydration secondary to viral gastroenteritis. Which room assignment is the most appropriate for this infant?

a private room Viral gastroenteritis may be communicable, and all of the other children are already at risk for infection. The infant should be placed in a private room.

The nurse is caring for a client with a nasogastric tube and in mitt restraints. Which nursing action is required every 1 to 2 hours?

Remove restraints and assess skin and circulation. Placing a client in any type of restraint is a controversial issue. Strict guidelines exist. The client in restraints must have the skin integrity and circulation assessed every 1-2 hours. It is also appropriate to massage the area and provide range of motion exercises. On a regular basis, the client would be offered to use a bedpan or ambulate to the bathroom and the nurse would assess the cognitive status. A client with a nasogastric tube would not be offered fluids.

The nurse is caring for a preschooler. Which technique will the nurse apply as most effective in preventing hospital-acquired infections in this population?

hand washing Hand washing is the single most important measure for preventing infection transmission. Personal protective equipment and using infection-control precautions are required for certain diseases, such as varicella, diphtheria, mumps, pertussis, measles, and meningitis. Standard precautions, which include hand washing, are guidelines for treating all clients as potentially infectious and protect the nurse and other clients from transmission, while hand washing specifically protects the client. A private room provides protection for high-risk clients and privacy for family members.

Which nursing intervention is appropriate for a client with an arm restraint?

monitoring circulatory status every 2 hours A nurse must assess the circulatory status of a restrained extremity every 2 hours to prevent circulatory impairment. To make sure the restraint is secure without compromising the circulation, the nurse should leave approximately one fingerbreadth between the restraint and the extremity. Tying a restraint to the side rail or an immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. The restrained arm or leg should be flexed slightly to allow joint movement without reducing the effectiveness of the restraint.

A nurse is teaching a new mother how to prevent burns in the home. Which statement by the mother indicates more teaching is required?

"I will heat my infant's formula in the microwave." Infant formula should never be heated in the microwave; the formula may heat at different temperatures and can burn the infant's mouth. Plastic bottle liners may also burst with the heat. Setting your hot water heater a couple of degrees cooler will help keep hot water in the house cooler (recommended since 1974 by the Consumer Product Safety Commission). Small children are at risk for scald injury from hot tap water due to their decreased reaction time, their curiosity, and the thermal sensitivity of their skin. Avoiding holding infants while drinking coffee can prevent possible spills onto children. Keeping cords tied up on the counter prevents children from pulling on dangling cords and spilling hot liquids over themselves.

A 29-year-old multigravida at 37 weeks' gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3 g/h. What is the priority intervention to maintain safety for this client?

Assess reflexes, clonus, visual disturbances, and headache. The central nervous system (CNS) functioning and freedom from injury is a priority in maintaining well-being of the maternal-fetal unit. If the mother suffers CNS damage related to hypertension or stroke, oxygenation status is compromised, and the well-being of both mother and infant are at risk. Continuous fetal monitoring is an assessment strategy for the infant only and would be of secondary importance to maternal CNS assessment because maternal oxygenation will dictate fetal oxygenation and well-being. In preeclampsia, frequent assessment of maternal reflexes, clonus, visual disturbances, and headache give clear evidence of the condition of the maternal CNS system. Monitoring the liver studies does give an indication of the status of the maternal system, but the less invasive and highly correlated condition of the maternal CNS system in assessing reflexes, maternal headache, visual disturbances, and clonus is the highest priority. Psychosocial care is a priority and can be accomplished in ways other than having the family remain at the bedside.

A nurse is preparing to administer an I.V. containing dextrose 10% in ¼ normal saline solution to a 6-month-old infant. The nurse should select which tubing to safely administer the solution?

I.V. tubing with a volume-control chamber Because infants have a small circulating blood volume, inadvertent administration of extra I.V. fluid can cause fluid volume excess. To prevent this from occurring, I.V. tubing with a volume-control chamber should always be used for infants and children to closely regulate the amount of fluid infused. The volume-control chamber should be filled only with enough I.V. fluid for the next two 2 hours. A microdrip chamber that allows for 60 drops/ml (as opposed to a macrodrip chamber, which allows for 10 to 20 drops/ml, depending on the manufacturer) should be used to infuse the smaller amounts of I.V. fluids an infant needs. A filter is typically used only for the administration of total parenteral nutrition and certain blood products. Standard I.V. tubing for adults should be avoided for infants because of the inability to closely regulate the amount of fluid infused.

Detention center staff asked for a mental health evaluation of a 21-year-old woman after the client stabbed themself with a fork and woke from nightmares in fits of rage. The evaluation revealed that the client was kidnapped and held from ages 8 to 16 by a convicted child pornographer. The client said they never contacted their family after being released from captivity. In what order of priority from first to last should the nurse implement the steps? All options must be used.

Initiate suicide precautions. Offer empathy and support, and be nonjudgmental and honest with the client. Encourage safe verbalizations of the client's emotions, especially anger. Ask the client if they wish to contact the their family while hospitalized. Safety is a priority after the client stabbed herself. A survivor of trauma/torture needs empathy, support, honestly, and a nonjudgmental stance from the nurse. Then the client is more willing to learn safe ways to express feeling, especially anger. It will be the client's decision if the client wants to contact their family and, if so, under what conditions. The client would need extensive preparation before any contact with family.

When explaining to parents how to reduce the risk of sudden infant death syndrome (SIDS) the nurse should teach about which measures? Select all that apply.

Maintain a smoke-free environment. Breastfeed the baby. Place the baby on his back to sleep. Exposure to environmental tobacco increases the risk for SIDS. Sleeping on the back and breastfeeding both decrease the risk of SIDS. The side-lying position is not recommended for sleep. It is recommended that babies be dressed in sleepers and that cribs are free of blankets, pillows, bumper pads, and stuffed animals. Co-bedding with parents is not recommended as parents may roll on the child.

A client recovering from an acute illness is extremely weak and unable to assist with transferring from the bed to a chair. Which action should the nurse take to ensure safety for both the client and nurse?

Obtain an assistive device to help with the transfer. If any healthcare provider is required to lift more than 35 pounds (16 kg) of a client's weight, the client should be considered fully dependent and assistive devices should be used for the transfer. Breaking the transfer down into smaller steps will not help if the client is unable to assist. A back belt has not been proven effective in preventing injuries. Additional bedrest will cause the client to become further weak and debilitated.

A parent tells the nurse that their 6-year-old child has severe nosebleeds. To manage the nosebleed, the nurse should tell the parent to:

place the child in a sitting position with the neck bent forward and apply firm pressure on the nasal septum. For the initial management of nosebleed, the client should sit up and lean forward with the head tipped downward. The soft tissues of the nose should be compressed against the septum with the fingers. The head-back position allows blood to flow down the throat, putting the client at risk for aspiration and allowing blood to enter the gastrointestinal tract, which can trigger vomiting.

A child with a body surface area (BSA) of 0.82 m2 has been prescribed actinomycin 2.5 mg/m2 intravenously. What is the correct amount to be given? Record your answer using two decimal places.

2.05 0.82 m2 × 2.5 mg/m2 = 2.05 mg

A nursing student and a preceptor nurse are discussing nursing liability. Which statement made by the student would indicate to the nurse that the student understands the concept of liability?

"Clients can still file a lawsuit outside of the statute of limitations if the the discovery of the harm has been more recent." Statute of limitations is the time period during which the injured party must file a case. Discovery rule refers to the time when the client discovers the injury. The statute of limitations typically allows clients to file a lawsuit within 2 years of discovery; however, the time may vary from state to state. Grace period refers to the contractually specified time during which payment is permitted, without penalty, beyond the due date of the debt. Alternative dispute resolution refers to any means of settling disputes outside the courtroom setting.

Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education?

"The client is receiving physical therapy twice per day, so they don't need a continuous passive motion device." Further staff education is needed when the nurse states that the continuous passive motion device isn't needed because the client receives physical therapy twice per day. The continuous passive motion device should be used in conjunction with physical therapy because the device helps prevent adhesions. Bleeding is a complication associated with the continuous passive motion device; skin integrity should be monitored while the device is in use.

An obese client has returned to the unit after receiving electroconvulsive therapy (ECT). A nurse requests assistance in moving the client from the stretcher to the bed. Which direction should the nurse give to a nurse who volunteers to help?

"Obtain the sliding board or two other people to assist us." To successfully move an obese client from the stretcher to the bed without incurring injury, at least four staff members must perform the transfer. If only two people are available, the nurse should use the sliding board. The hydraulic lift isn't the appropriate equipment to use with a sedated patient. The nurse shouldn't place the client in a semi-Fowler's position unless there is a head injury or other complicated medical condition. To perform a safe transfer using a drawsheet, the nurse must place the sheet directly under the client's body.

During a home visit the nurse observed a mother giving her infant a bath. The nurse documents "Risk for injury (fall) related to parent's knowledge deficit." Which instruction by the nurse best addresses this nursing diagnosis?

"Support the neonate's head and back with the forearm." To maintain a secure grip while bathing the neonate, the nurse should support the neonate's head and back with the forearm. A loose hold may increase the risk of dropping the neonate. The nurse must support the neonate's back and head. Strapping the neonate into the bath basin is inappropriate and confining and precludes optimal physical contact.

A client is being admitted with nursing home-acquired pneumonia. The unit has four empty beds in semiprivate rooms. The room that would be most suitable for this client is the one with which other client?

60-year-old client admitted for investigation of transient ischemic attacks. The client with a possible transient ischemic attack is the only client who has not had surgery and is not immunocompromised. The client with a recent surgery and incision should not be exposed to a client with infection. Clients with cancer or alcoholic cirrhosis are very susceptible to infection, and it would not be safe to expose them to a client with a respiratory infection.

A client is receiving chemotherapy for the diagnosis of brain cancer. When teaching the client about contamination from excretion of the chemotherapy drugs within 48 hours, what should the nurse tell the client?

Any contaminated linens should be washed separately and then washed a second time, if necessary. The client may excrete the chemotherapeutic agent for 48 hours or more after administration. Blood, emesis, and excretions may be considered contaminated during this time, and the client should not share a bathroom with children or pregnant women. Any contaminated linens or clothing should be washed separately and then washed a second time, if necessary. All contaminated disposable items should be sealed in plastic bags and disposed of as hazardous waste.

A client who has an abdominal dressing has asked to use the urinal. A nurse drops a clean glove on the floor while attempting to don gloves. In which order, from first to last, should the nurse proceed?

Apply new, clean gloves. Assess the client's surgical dressing. Reposition the client's urinal. Dispose of the glove on the floor. The nurse should always work from least contaminated to most contaminated area. If the nurse picks up and disposes of the glove on the floor, the hands are contaminated and the nurse will need to repeat hand hygiene before caring for the client. The nurse should first put on a new pair of clean gloves and then assess the client's surgical dressing. The nurse can next assist the client with using the urinal, and last, the nurse can pick up and dispose of the glove on the floor. It is more time efficient to dispose of fallen objects when all client care is complete unless the fallen object is required to proceed with client care.

A client recovering from a stroke is prescribed a leg brace and needs to be transferred out of bed to a chair. Which action should the nurse take first before beginning this transfer?

Apply the leg splint before beginning the transfer. It is recommended that any braces or devices the client wears to be applied before assisting the client out of bed. The head of the bed should be raised so that the client is in a sitting position before beginning the transfer. There is no reason to roll the client away from the side of the transfer. This would not facilitate the movement and could cause injury to both the client and nurse during the transfer.

While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. In which order of priority from first to last should the nurse take the actions? All options must be used.

Assess the client's current condition and vital signs. If no acute injury, get help, and carefully assist the client back to bed. Notify the client's health care provider (HCP) and family. Document as required by the facility. The nurse should first assess the client and then, if there is no acute injury, help the client get back into bed. The nurse must notify the HCP and the family of the client who fell and, finally, document the event on the client's health record.

A client who was discharged earlier in the day returns to the nursing unit and demands acetaminophen with codeine. The client is advised that the client is no longer being treated on the unit and this medication cannot be administered. The client states, "I know where you park your cars, and you'd better watch out when you leave here tonight." What is the next step that the nurse should take?

Call the police. The nurse should call the police because threatening staff is a criminal act. Nursing supervisors are not able to take the same actions as police officers to protect the staff. Asking to meet with the client privately is unsafe; the client's behavior is unpredictable, and the client could be a risk to others or self. Calling the client's family is not appropriate given the threats uttered.

The nurse is instructing the spouse of a client who had an incision and drainage procedure for an abscess how to care for the wound at home. What information should the nurse give the spouse about cleaning the wound?

Clean both sites independently. The sites should be treated as separate sites to avoid cross contamination. This adheres to the principle of cleaning from the least contaminated area to the most contaminated area. Each site is considered a separate area for wound care.

A nurse and a nursing student drive to the home of a client with postpartum depression and discover the client and her baby completely naked in the backyard. The client is unable to communicate in an effective manner. What is the nurse's most appropriate response to resolve this situation?

Contact the nursing supervisor to clarify the appropriate actions in this acute mental health situation. The nurse should contact the immediate nursing supervisor to clarify or guide the correct nursing actions in this acute mental health situation. Community mental health services may be available that could visit the home and assess and intervene in this situation. The nurse should help the mother and baby inside and stay with them until the supervisor advises how best to manage the situation. It is inappropriate to call the client's partner and have them come home because the nurse first needs to assess and address any immediate safety concerns for the mother and baby. Asking the nursing student to remain with this client while the nurse leaves is inappropriate because this may jeopardize the safety of the nursing student. In addition, given the context, the care required may be beyond the nursing student's scope of practice.

The nurse is ready to administer a partial fill of imipenem-cilastatin in the IV pump when a full partial fill bag of imipenem-cilastatin is found hanging at the client's bedside. What should the nurse do?

Determine when the client received the last dose of the imipenem-cilastatin. The nurse should first determine whether the client received the last dose of imipenem-cilastatin. If the client did not receive the last dose, the nurse should notify the health care provider (HCP) that the client did not receive the dose, receive prescriptions, document, implement the prescriptions, and complete an incident report. The nurse should not automatically discard the partial fill of imipenem-cilastatin found at the client's bedside until further investigation is done. The nurse should recognize the cost of medications such as imipenem-cilastatin and consult the pharmacist after identifying information on the partial fill bag that was found. After verifying all information, the nurse can administer the new partial fill of imipenem-cilastatin so that the client can receive the antibiotic on time.

A nurse is administering a newly prescribed I.V. antibiotic to a client who suddenly develops wheezing and dyspnea. Which is the nurse's priority action?

Discontinue the antibiotic infusion. The nurse should first discontinue the antibiotic because it is the most likely cause of the allergic reaction. Next, oxygen should be administered followed by administration of epinephrine and/or diphenhydramine as ordered.

The nurse has restrained an infant. Which actions by the nurse are indicated? Select all that apply.

Document the reason for use and effectiveness of the restraint. Inspect the skin for areas of pressure. Secure the ties for quick release. Using restraints requires a primary care provider's prescription; the nurse should document the reason for use and effectiveness of the restraint. The nurse should also inspect the skin for areas of pressure caused by the restraint and remove the restraint periodically to provide skin care and range of motion. The ties should be secured so they can be released quickly if needed; the ties should be fastened to the bed springs, not the rails of the crib or the mattress. The belt restraint is positioned correctly; the restraint will limit the infant's movement yet allow for changing the diaper. The restraint should limit the infant's movement and not enable the infant to move from side to side.

A nurse implements a healthcare facility's disaster plan. Which action should be performed first?

Identify a command center at which activities are coordinated. During a disaster, having a command center to provide direction and coordinate activities is crucial. Cellular phones and pagers may be essential communication tools during a disaster. Essential off-duty personnel should respond to a disaster as quickly as possible. Admitted clients should be triaged and treated in accordance with the facility's triage policy.

The nurse is preparing the room for a client diagnosed with varicella. Identify which sign the nurse would place on the room door.

In addition to contact precautions, the nurse would place the client diagnosed with varicella in airborne precautions. Airborne precautions include a face mask for the client/respirator for the nurse and personal protective equipment including gown and gloves. Droplet precautions are indicated for viruses, B. ordetella pertussis, and group A streptococcus. Contact precautions are indicated anytime a nurse may come in contact with any body fluids.

A nurse is teaching parents about accident prevention for a toddler. Which guideline is most appropriate?

Make sure all medications are kept in containers with childproof safety caps. Making sure all medications are kept in containers with childproof safety caps is the most appropriate guideline because poisoning accidents are common in toddlers owing to the toddler's curiosity and his increasing mobility and ability to climb. When riding in a car, a toddler should be strapped into a car seat, not a seat belt. A seat belt is an appropriate guideline for a school-age child. Never leaving a child alone on a bed is an appropriate guideline for parents of infants. Toddlers already have the ability to climb on and off of beds and other furniture by themselves. Note, however, that toddlers should never be left unattended on high surfaces, such as an examining table in a physician's office. Teaching the rules of the road for bicycle safety is an appropriate safety measure for a school-age child. Toddlers should not be allowed in the road unsupervised.

A client moves in with her family after her boyfriend of 4 weeks told her to leave. She is admitted to the subacute unit after reporting feeling empty and lonely, being unable to sleep, and eating very little for the last week. Her arms are scarred from frequent self-mutilation. What should the nurse do in order of priority from first to last? All options must be used.

Monitor for suicide and self-mutilation. Monitor sleeping and eating behaviors. Discuss the issues of loneliness and emptiness. Discuss her housing options for after discharge. Safety is the priority concern, and then eating and sleeping patterns need to be reestablished. After intervening to meet basic needs, delving into the loneliness and emptiness are important for determining underlying issues that need to be followed up in outpatient counseling. Although the client is living with her family currently, other options might be appropriate for her to consider.

The nurse observes a family member of a client who is on contact precautions enter and exit the client's room without performing hand hygiene. What is the nurse's most appropriate action?

Offer to show family members how to perform hand hygiene using soap and water or alcohol rub. The nurse should address the family member's oversight and promote infection control, but in a way that is nonconfrontational. Offering to show the family members how to perform hand hygiene achieves these goals. Moving signage may not result in a behavior change. Speaking about hospital-acquired infections may not result in improved hand hygiene.

What is the nurse's most important intervention for a client having a tonic-clonic seizure?

Protect the client from further injury The priority during and after a seizure is to protect the person from injury by keeping them from falling to the floor. Furniture or other objects that be a source of injury during the seizure should be moved out of the client's way. Timing the seizure, and noting the origin of the seizure are important, but are not the priority. Nothing should be placed in the client's mouth during a seizure because teeth may be dislodged or the tongue pushed back, further obstructing the airway.

A client living in a long-term care facility has become increasingly unsteady when out of bed. The nurse is worried that the client is going to climb out of bed and fall. The facility has a least restraint policy for the clients. Which action should the nurse take to best ensure the safety of the client while complying with policy?

Provide a bed that is low to the floor. Providing a bed that is low to the floor complies with the least restraint policy and prevents falls from the bed. Raising all side rails on the bed would be considered excessive restraint and could contribute to greater risk of injury if the client tried to climb out of bed. The other options do not fully ensure the safety of the client.

A graduate nurse is learning about medical management of clients that experience a reaction. What intervention should be included in the treatment of a client that is cyanotic and experiencing dyspnea? Select all that apply.

Provide supplemental oxygen. Administer epinephrine intravenous infusion. Providing supplemental oxygen will help with the client's cyanosis and dyspnea. An epinephrine infusion will help decrease edema and increase blood pressure by causing vasoconstriction. Methylprednisolone sodium succinate would be given as adjunct therapy. Vital signs would need to be monitored more frequently, every 15 minutes to an hour until the client is stable. Intake and output would need to be monitored more frequently, every hour until the client is stable.

A hospital nurse is on the safety committee. Which should the nurse recommend to the hospital administration to reduce needle-stick injuries at the institution? Select all that apply.

Purchase safety needle devices Encourage staff to plan safe handling and disposal of needles before initiating a procedure Post signs reminding staff to dispose of needles immediately after use Remind staff to use the "scoop" technique for recapping needles The nurse should not recap needles. Choosing safety needle devices whenever possible and appropriate; planning in advance how to handle and dispose of needles; and discarding needles, safety needle systems, and sharps in sharps-disposal containers immediately after use are safe ways to handle sharps with less risk of needle-stick injuries. The nurse should use the one-handed needle-recapping technique only when absolutely necessary, such as when a sharps-disposal container is not readily available.

Which action should the nurse include in the plan of care for a child with leukemia who has an absolute neutrophil count of 400/mm3 (0.4 X 109/L)?

Restrict staff and visitors with active infections. The child's neutrophil count is low (the normal range is 3,000 to 5,000 cells/mm3 [3 to 5 X 109/L]), predisposing the child to infection. If an infection occurs, the child will have difficulty combating it. Therefore, staff and visitors should be restricted to those without an active infection. Typically neutropenic precautions, not strict isolation, would be used to protect the child from exposure to infection. The hospitalized child would be placed in a private room with visitors and staff screened for illnesses. Temperature would be monitored every 4 hours. Low neutrophil counts do not increase the likelihood of vomiting; therefore, an antiemetic is not needed. Increasing the child's oral fluid intake may be necessary; however, doing so is unrelated to the child's neutrophil count.

A charge nurse learns of another nurse who has had two unsuccessful attempts at starting a peripheral IV for a child. What is the most appropriate action by the charge nurse?

Speak to the nurse about the situation and offer to start the child's IV. When starting a peripheral IV for a child, no more than two attempts at insertion should be made by one nurse. Therefore, the charge nurse should interrupt the nurse and offer to start the IV. In children, total attempts at IV insertion should be limited to four because multiple unsuccessful attempts cause the child unnecessary pain, delay treatment, and increase the risk of complications.

A client with end-stage chronic obstructive pulmonary disease (COPD) requires bi-level positive airway pressure (BiPAP). While caring for the client, the nurse determines that bilateral wrist restraints are required to prevent compromised care. Which client care outcome is best associated with restraint use in the client who requires BiPAP?

The client will maintain adequate oxygenation. BiPAP is a type of continuous positive airway pressure in which both inspiratory and expiratory pressures are set above atmospheric pressure. This type of ventilatory support assists clients with COPD who retain PaCO2. Restraints are necessary in this client to maintain BiPAP therapy if the client attempts to dislodge the mask despite instruction not to do so. Maintaining oxygenation is the expected outcome in this client. Remaining safe, understanding the rationale for restraints, and collaborating with the health care team to begin discharge planning are important, but not the best outcome with relation to BiPAP.

A nurse realizes she is 1 hour late in administering a dose of medication for a 4-year-old child. She gives the medication immediately, and assesses the child. The child isn't harmed by the delay. Which action should the nurse take next?

The nurse should follow facility procedures for reporting an error. Although no harm came to the child, this scenario is an example of a medication error. The nurse should follow the facility's procedure for reporting the error because it allows the facility to adequately assess the causes of medication errors, and isn't meant to place blame on any one person. The nurse in this instance doesn't need to notify the physician because there was no harm to the child. Also, the nurse shouldn't document that an error took place in the child's chart; doing so may place her at risk in the event of a lawsuit.

The nurse is evaluating infection control practices performed by a spouse on a loved one who has methicillin resistant Staphylococcus aureus (MRSA) in a right leg wound. Which actions indicate that the spouse requires further teaching? Select all that apply.

The spouse places soiled dressing supplies in the kitchen garbage can. Sheets with wound drainage are washed in lukewarm water. Methicillin resistant Staphylococcus aureus (MRSA) is a bacterium that causes infections in different parts of the body and is resistant to some commonly used antibiotics. Infection control practices prevent the spread of the infection. Further teaching is needed if a nurse notes that soiled dressing supplies are placed in a community garbage can such as one located in the kitchen. Soiled sheets need to be wash in hot water and dried in a clothes dryer. It is correct to clean and disinfect the area where dressing supplies are prepared. Routine hand hygiene followed by wearing clean gloves is appropriate when removing the dressing. Sterile gloves may be needed when completing dressing care.

The nurse is taking care of a client with Clostridium difficile. To prevent the spread of infection, what should the nurse do? Select all that apply.

Wash hands with soap and water. Wear a protective gown when in the client's room. C. difficile is an organism that has developed very resistant and highly morbid strains. Universal precautions, most importantly handwashing, wearing personal protective gear, and modest use of antibiotics, are critical actions for stopping the spread. C. difficile is not spread via the respiratory tract; therefore, a mask is not needed. Alcohol-based hand sanitizers do not kill the spores of C. difficile; soap and water must be used. Sterile gloves are not needed to provide care; clean gloves may be worn.

The nurse is teaching a client newly diagnosed with a peanut allergy about how to manage the allergy. What information should be included in the teaching? Select all that apply.

Wear a medic alert bracelet. List symptoms of peanut allergy. Identify ways to manage allergy while dining out. Carry EpiPen autoinjector at all times. Wearing a medic alert bracelet allows others to be alerted of the allergy. Listing symptoms of the allergy makes the client aware of the allergic reaction if symptoms are being experienced. Identifying ways to manage allergies while dining out allows the client to be safe from a potential reaction. All food labels should be read not only baked items. The EpiPen autoinjector should be carried at all times in case it needs to be administered because of an allergic reaction.

When developing the teaching plan for a client who uses a walker, which principle should a nurse consider?

When maximum support is required, the walker should be moved ahead approximately 6″ (15 cm) while both legs support the client's weight. To prevent falls, a client who needs maximum support should move the walker ahead approximately 6″. The client's legs should bear the weight of his body. The hand bar of the walker should be level with the client's waist, not below it. If one leg is weaker than the other, the walker and the weak leg move together while the stronger leg bears the client's weight. To use a standard walker correctly, a client should pick it up to move it. However, some walkers have wheels and can glide across the floor.

Using the Morse Fall Risk scale (see exhibit), the nurse should initiate highest fall risk precautions for which client?

a 62-year-old client with a history of Parkinson's disease, admitted for pneumonia and receiving IV antibiotics, who has fallen at home but is able to ambulate with a cane and who during his hospitalization has gotten out of bed without calling for assistance Using the Morse fall scale, risk factors for this client include history of falling, secondary diagnosis, ambulatory aid, IV/heparin lock, weak gait/transfer, and forgetting limitations (100 points). Client no. 1 is also high risk with a secondary diagnosis, history of falling, IV access, and confusion but is on bed rest (75 points). Client no. 2 risks include IV access and secondary diagnosis (35 points). Client no. 4 is at risk due to his IV access only (20 points).

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?

a client with a nasogastric tube Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.

Which client is at highest risk for developing a hospital-acquired infection?

a client with an indwelling urinary catheter The invasive nature of an indwelling urinary catheter increases the client's risk of a hospital-acquired infection. The nurse must perform careful, frequent catheter care to minimize the client's risk. Although the client with a laceration, the client who's taking prednisone, and the client with Crohn's disease have a risk of infection, the one with an indwelling catheter is at the greatest risk.

A nurse is leading a group of parents of toddlers in a discussion on home safety. The nurse should share what information about the most common cause of toddler deaths?

accidents Most toddler deaths are accidental. Many injuries or deaths in this age group result from fire, drowning, motor vehicle accidents, and firearms. For children 1-4 years old, the most common cause of unintentional injury death is from drowning. Infants under 1 year of age have the highest risk of death from suffocation Toddlers are at a high risk for injury because of their developmental level and their limited ability to distinguish right from wrong and to recognize danger signs. The highest number of deaths of children between 5 and 14 years old is automobile crashes. Toddlers have lower numbers because they are supported in car seats.

A nurse discussing injury prevention with a group of workers at a daycare center is focusing on toddlers. When discussing this age-group, the nurse should stress that

accidents are the leading cause of death among toddlers. The leading cause of death in toddlers is accidents, so it's important for parents, family members, and childcare providers to understand the importance of accident prevention. Toddlers don't have the highest risk for homicide. Toddlers are just beginning to understand right from wrong, but don't understand the consequences of their actions. Although many children will chase balls or toys into the street, not all children will do so.

A client is prescribed to ambulate with a cane. Which action should the nurse take when helping the client use this assistive device? Select all that apply.

advance the weaker leg after advancing the cane. Instruct the client to hold the cane on the stronger side of the body. Ensure the cane height causes the elbow joint to flex at 30 degrees. When assisting a client use a cane, the height of the cane should be around the level of the hip joint so that the elbow joint is flexed at 30 degrees. The cane is held on the stronger side of the body. The cane is advanced first, followed by the weak leg. The strong leg is not advanced after advancing the cane. The cane and strong leg are not advanced together.

A hospital safety officer is evaluating nurses' responses to potential safety hazards. Which employee actions are appropriate for the situation? Select all that apply.

aking small steps with feet shoulder length apart when walking on wet surfaces removing clients from the area where a fire is reported using tongs to place a dislodged radioactive device in a lead container There are a number of situations that could compromise safety where an appropriate response will minimize risk. People should not walk under ladders, move unidentified objects during a bomb threat, or directly touch radiation sources. Clients should be safe before an employee starts to fight a fire. Wet conditions make footing slippery, so if it is necessary to walk on a wet surface the person should use a wide base of support and take small steps.

The nurse teaches a safety and accident prevention class to a group of third graders. Which preventive measure should the nurse stress during the first class?

car safety Motor vehicle accidents are the most common cause of accidental injury and death in children ages 1 to 12 years. Measures should be emphasized that prevent accidents involving motor vehicles, bicycles, or motorized bikes. Therefore, car safety should be emphasized. This includes keeping children in a booster seat until they are 4 feet 9 inches (145 cm), which typically occurs between the ages of 8 and 12. After reaching that height, children must still ride in the backseat until they are older than 12 years of age. A seatbelt should be used anytime the child rides in a car.Burns are a major cause of accidental injury in children under 1 year of age to school age, and flame-retardant clothing would be an appropriate safety strategy. However, because burns are not the most common cause, this topic could be dealt with after discussing motor vehicle safety.Drowning is a major cause of accidental injury and death in school-aged children, and the use of life preservers is appropriate. However, because drowning is not the most common cause, this topic could be dealt with after discussing motor vehicle safety.Eye injuries do occur, but they are not the most common cause of accidental injury and death in children 1 to 12 years of age.

The nurse is planning care for a client in restraints. Which nursing intervention is most important when restraining this client?

checking that the restraints have been applied correctly A nurse must determine whether the restraints have been applied correctly to make sure that the client's circulation and respiration are not restricted, and that adequate padding has been used. The nurse should document the client's response and status carefully after the restraints are applied. All staff members involved in restraining clients should be aware of facility policy before using restraints. If an as-needed medication is ordered, it should be administered before the restraints are in place and with the assistance of other team members. The nurse should attend to the client's elimination and hydration needs after the client is properly restrained.

The nurse is completing morning assessments and finds a client not wearing a name band. What priority actions will the nurse take to ensure correct client identification? Select all that apply.

confirm identification with the client using two identifiers. Obtain a new identification name band. Ask the previous nurse to verify client identification. The nurse will need to confirm identification with the client using two identifiers, obtain a new identification name band, and ask the previous nurse to verify client identification. Investigating why the client's name band is missing and using the medical record is not sufficient for client identification and does not fix the issue of the missing name band.

The nurse is assigning a room for a client admitted with hepatitis A. Which diagnosis would be an appropriate roommate for this client?

congestive heart failure The nurse needs to determine the need for specific standard and transmission-based precautions. It would be appropriate for a hepatitis A and congestive heart failure client to share a room, as neither requires isolation. The varicella is airborne isolation and must be in a private negative airflow room. Postoperative clients should not be in a room with a medical client with a communicable infection.

The nurse is admitting a child who has been diagnosed with bacterial meningitis to the pediatric unit. The nurse should implement which type of isolation?

droplet precautions Bacterial meningitis is caused by one of three organisms, Haemophilus influenzae type b, Neisseria meningitidis, or Streptococcus pneumoniae. All three organisms may be transmitted through contact with respiratory droplets. These droplets are heavy and typically fall within 3 feet (91.4 cm) of the client. Droplet precautions require, in addition to standard (routine) precautions, that HCPs wear masks when coming into close contact with the client. Standard or routine precautions, previously referred to as universal precautions, are general measures used for all clients. Contact precautions are used when direct or indirect contact with the client causes disease transmission. Gowns and gloves are needed but not masks. Airborne precautions differ from droplet in that the particles are smaller and may stay suspended in the air for longer periods of time. These clients require negative pressure rooms, and all heath care workers must wear respirators.

What type of isolation precautions would the nurse request for a child diagnosed with group-A beta-hemolytic streptococcus?

droplet precautions Group-A beta-hemolytic streptococcal infections are spread through droplets. Standard and contact precautions would not be sufficient to decrease transmission. Group-A beta-hemolytic streptococcal infections do not require specialized masks.

The nurse is admitting a 4-year old with a possible meningococcal infection. Which type of isolation is indicated?

droplet precautions Meningococcal infections are spread through close mucous membrane or respiratory contact with large respiratory droplets. Meningococcal infections are not spread by small airborne organisms or contact with a person's skin or contaminated items. Standard precautions, used when touching body fluids, are not sufficient to prevent the spread of meningitis.

A young female client is receiving chemotherapy and mentions to the nurse that she and her husband are using a diaphragm for birth control. Which information is most important for the nurse to discuss?

infection control The risk of becoming neutropenic during chemotherapy is very high. Therefore, an inserted foreign object such as a diaphragm may be a nidus for infection. Although the nurse may wish to inform the client about the ease with which various contraceptive modalities may be used, the focus of this discussion should be on preventing an infection, which can be fatal for the neutropenic client. There are no data to suggest the client is at risk for acquiring a sexually transmitted disease. The client will not be experiencing body changes directly related to hormonal changes.

In which areas of the United States and Canada is the incidence of tuberculosis highest?

inner-city areas Statistics show that of the four geographic areas described, most cases of tuberculosis are found in inner-core residential areas of large cities, where health and sanitation standards tend to be low. Substandard housing, poverty, and crowded living conditions also generally characterize these city areas and contribute to the spread of the disease. Farming areas have a low incidence of tuberculosis. Variations in water standards and industrial pollution are not correlated to tuberculosis incidence.

A client is experiencing dryness in the nares while receiving oxygen via nasal cannula at 4 L/minute. Which medication should the nurse apply to help alleviate the dryness?

lubricant jelly Lubricant jelly is a water-soluble agent that the nurse can apply safely during oxygen therapy to alleviate dryness of the nares. Petroleum jelly is combustible; it isn't safe to use with oxygen. The nurse shouldn't use sterile water or antibiotic ointment to alleviate dryness in the nares.

The primary goal in the plan of care for the client after cataract removal surgery is to:

promote safety at home. Promoting safety is a priority goal for this client. The client's vision will not be clear, and the client may need to wear an eye patch after surgery. Orienting the client to the physical environment, assisting the client during ambulation, and following other safety precautions to reduce the risk of injury are required. Cardiac output and fluid volume excess are unrelated to cataract surgery. Maintaining a darkened environment is neither necessary nor safe.

The nurse is assisting a community to develop primary prevention strategies for its disaster management plan. What action should the nurse recommend? Select all that apply.

reating a risk map developing a resource map planning an evacuation route Creation of a risk map and resource map as well as the determination of lines of authority are all appropriate primary prevention strategies. Planning an evacuation route is also a primary prevention strategy. Restoration of power after an outage during an emergency is a secondary prevention strategy. Triaging victims is also a secondary prevention strategy.

A nurse notes the following laboratory values for a client receiving chemotherapy: white blood cell count 6000/µL, red blood cell count (RBC) 3.7 million cells/cm3, hematocrit 35%, platelet count 80,000 mm3. Which order would the nurse question?

rectal temperatures every 4 hours The platelet count indicated that the client is a risk for bleeding. The low RBC can cause fatigue, so the activity order is appropriate. The hematocrit is reflective of the low RBC count. The white blood cell count is normal, so a semiprivate room or restricted diet is acceptable.

A client says to the nurse, "My intravenous line hurts." The nurse assesses the client's peripheral intravenous line and suspects phlebitis. What assessment data confirm the nurse's suspicion? Select all that apply.

redness pain around the infusion site warmth edema above the insertion site Redness, warmth, pain, and edema are all signs and symptoms of phlebitis. Respiratory distress is a sign of an air embolus.

The nurse is placing patches on both eyes of client with detachment of the retina. What is the expected outcome of patching?

reduced rapid eye movements Patching the eyes helps decrease random eye movements that could enlarge and worsen retinal detachment. Although clients with eye injuries frequently are light sensitive, and preventing infection is important, the specific goal is to reduce rapid eye movements. Using the uninvolved eye would not cause eye strain, but random movements of one eye will involve the other eye.

A client with bacterial meningitis is admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use?

respiratory isolation Because bacterial meningitis is transmitted by droplets from the nasopharynx, the nurse should prepare to use respiratory isolation. This type of isolation involves wearing a gown and gloves during direct client care and ensuring that everyone who enters the client's room wears a mask. Reverse isolation is unnecessary because it's used for immunosuppressed clients who are at high risk for acquiring infection. Strict hand washing and standard precautions are insufficient for this client because they don't require the use of a mask.

Which activity should the nurse recommend to the client on an inpatient unit when thoughts of suicide occur?

talking with the nurse Talking with a staff member when suicidal thoughts occur is an important part of contracting for safety. The nurse or another staff member can then assess whether the client will act on the thoughts and assist the client with methods of coping when suicidal ideation occurs. Writing in a journal, engaging in physical activity, or playing games with others does not allow the client to verbalize suicidal thoughts to the nurse.

A nurse inadvertently gives a client a double dose of an ordered medication. After discovering the error, whom should the nurse notify first?

the prescriber After discovering a medication error, the safety of the patient is top priority. The nurse should immediately check the client and observe for any adverse effects which may develop. The first person the nurse needs to notify is the prescriber, followed by the nursing manager (or the nursing supervisor). Then pharmacist and risk manager should also be notified.

A nurse reports to the hospital occupational health nurse (OHN) that the nurse was splashed with blood during the resuscitation of an HIV-positive client. The nurse asks the OHN when test results will show positive or negative for HIV infection for the nurse. Which is the most appropriate response by the OHN?

"Accurate results will be obtained by testing at 3 months and again at 6 months." Ninety-five percent of exposed individuals will seroconvert within 3 months; 99% will convert by 6 months. The other options do not accurately reflect the timeline for seroconversion following exposure.

A nurse who is 6 months pregnant is assigned to a client with a diagnosis of HIV. The nurse tells the manager that she is unable to care for the client because it would be a risk to her baby. Which is the most appropriate statement by the manager?

"You will be OK if you follow standard precautions and use protective equipment to avoid contact with blood and body fluids when providing care." By following standard precautions and using personal protective equipment when exposed to or handling blood or body fluids there should be no risk of exposure. The other options are either ineffective or not necessary when caring for a client who is HIV positive.

A nurse is verifying a medication calculation completed by a nursing student prior to administration. The adult client is to receive ampicillin 150 mg/kg/day I.V. divided in 6 even doses with a maximum dose of 12 g/day. The client's weight is 80 kg. How many mg/dose will the client receive? Record your answer using whole number.

2000 The nurse should verify that the total dosage will not exceed the maximum dosage of 12 g/day. 150 mg/kg / day x 80 kg = 12,000 mg/day ÷ 6 doses = 2,000 mg per dose

A nurse is supervising a new graduate registered nurse who is caring for a client hospitalized with active tuberculosis (TB). Which action by the new graduate requires the nurse to intervene?

A surgical face mask is applied before entering the client's room. A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the client's room because the HEPA mask can filter out 100% of small airborne particles. All of the other interventions are correct and appropriate for the nurse to perform.

A client who is allergic to penicillin has a prescription to receive cefazolin. What should the nurse do first?

Ask if the client has taken cefazolin before without an adverse response. A client who has an allergy to penicillin may have a cross-sensitivity to cefazolin, a first-generation cephalosporin, and the drug should be given with caution. The nurse should ask the client whether he has taken cefazolin before. The nurse should inform the pharmacy of the client's allergy after asking the client about prior use of cefazolin. The medication should not be administered until the nurse first inquires about the client's exposure to cefazolin and then consults the pharmacist or HCP. Observing the client for urticaria is appropriate but is not an initial response.

The nurse is caring for an immune-compromised client with a fungal infection of the scalp. What recommendation should the nurse make to prevent future problems?

Avoid sharing combs and brushes. Tinea capitis is a fungal infection of the scalp that occurs in hot, humid environments. Risk factors include exposure to daycare centers or pets with the infection, poor hygiene, diabetes, immune system disorders, and the sharing of combs, brushes, or hats. Washing the hair helps, but dandruff-preventing shampoo will not prevent the condition. The health problem can occur with any length of hair.

The client has returned to the surgery unit from the postanesthesia care unit (PACU). The client's respirations are rapid and shallow, the pulse is 120 bpm, and the blood pressure is 88/52 mm Hg. The client's level of consciousness is declining. What should the nurse do first?

Call the rapid response team (RRT)/medical emergency team. The nurse should first call the rapid response team (RRT) or medical emergency team that provides a team approach to evaluate and treat immediately clients with alterations in vital signs or neurological deterioration. The client's vital signs have changed since the client was in the PACU, and immediate action is required to manage the changes; the staff in PACU are not responsible for managing care once the client is transferred to the surgical unit. The respiratory therapist may be a part of the RRT but should not be called first.

A client has soft wrist restraints to prevent the client from pulling out the nasogastric tube. Which nursing intervention should be implemented while the restraints are on the client?

Check on the client every 30 minutes while the restraints are on. The application of restraints places the client in a vulnerable, confined position. The nurse should check on the client every 30 minutes while restrained to make sure that the client is safe. The client should be able to move while the restraints are in place. The restraints should be removed every 2 hours to provide skin care and exercise the extremities. Restraints should not be secured to the side rails; they should be secured to the movable bed frame so that when the bed is adjusted the restraints will not be pulled too tightly.

A nurse notes that another nurse on the previous shift made an entry on the wrong client's health record. What are the most appropriate steps for the first nurse to take?

Contact the previous nurse requesting that the nurse correct the error. The nurse who wrote the original record and performed the care must make the correction to health record. Nurses have a responsibility to ensure documentation is clear, accurate, and concise to ensure continuity of care. The other options are incorrect because they do not follow established procedures for correcting legal medical records.

The staff of an outpatient clinic has formed a task force to develop new procedures for swift, safe evacuation of the unit. The new procedures haven't been reviewed, approved, or shared with all personnel. When a nurse-manager receives word of a bomb threat, the task force members push for evacuating the unit using the new procedures. Which action should the nurse-manager take?

Determine that the procedures currently in place must be followed and direct staff to follow them without question. In an emergency such as a bomb scare, the nurse-manager must determine, without hesitation, the best action for the safety and welfare of clients and staff. Allowing staff members to do whatever they think best will cause confusion and inefficient client evacuation because no one will know how to function effectively as a team during the crisis. A staff meeting would waste valuable time.

The client has a latex allergy. What should the nurse teach the client to do before having surgery? Select all that apply.

Determine that there will be a latex-safe environment for surgery. Report symptoms experienced with the latex allergy (e.g., rhinitis, conjunctivitis, flushing). Notify the health care providers (HCPs) at the surgery center. Treatment and diagnostic evaluation must be done in a latex-safe environment. Signs and symptoms of latex allergy may range from mild to anaphylaxis. Clients with latex allergy are advised to notify their HCPs and to wear a medical ID; however, all metal and jewelry must be removed prior to surgery as they could conduct an electrical current. The surgery can be safely performed at a free-standing surgery center as long as latex precautions are observed.

The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used.

Ease the client to the floor. Maintain a patent airway. Obtain vital signs. Record the seizure activity observed. To protect the client from falling, the nurse first should ease the client to the floor. It is important to protect the head and maintain a patent airway since altered breathing and excessive salivation can occur. The assessment of the postictal period should include level of consciousness and vital signs. The nurse should record details of the seizure once the client is stable. The events preceding the seizure, timing with descriptions of each phase, body parts affected and sequence of involvement, and autonomic signs should be recorded.

When checking a client's medication profile, a nurse notes that the client is receiving a drug contraindicated for clients with glaucoma. The nurse knows that this client, who has a history of glaucoma, has been taking the medication for the past 3 days. What should the nurse do first?

Hold the medication and report the information to the physician to ensure client safety. The nurse should report the information to the physician because the client's safety may be endangered. The nurse shouldn't give the drug until clarifying the order with the physician. The fact that the client has taken the drug for several days doesn't guarantee that giving another dose is safe. Filing an incident report and finding out whether there are extenuating reasons for giving the drug wouldn't address client safety.

The nurse is caring for a toddler who is visually impaired. What is the most important action for the nurse to take to ensure the safety of the child?

Maintain a tidy environment around the child. Visually impaired children explore their environment by feel. A tidy and organized environment can support this and promote the child's safety. It is a priority to make sure all items that could potentially injure the child are removed from the environment. This includes meal trays and supplies for procedures.

A mother of a 5-year-old child who was admitted to the hospital has a Protection from Abuse order for the child against his father. A copy of the order is kept on the pediatric medical surgical unit where the child is being treated. The order prohibits the father from having any contact with the child. One night, the father approaches the nurse at the nurses' station, politely but insistently demanding to see his child, and refusing to leave until he does so. What should the nurse do first?

Notify hospital security or the local authorities. The Protection from Abuse order legally prohibits the father from seeing the child. In this situation, the nurse should notify hospital security or the local authorities of this attempt to breach the order, and allow them to escort the father out of the building. The father could be jailed or fined if he violates the order. The nurse shouldn't argue or continue explaining to the father that he must leave because it could place the nurse and the child at risk if the father becomes angry or agitated. The nursing coordinator and nurse-manager should be notified of the incident; the nurse's first priority, however, should be contacting security or the authorities.

What should the nurse do to ensure safety for a hospitalized blind client?

Orient the client to the room environment. The priority goal of care for a client who is blind is safety and preventing injury. The initial action is to orient the client to a new environment. Taking time to identify the objects and where they are located in the room can achieve this goal. It is unrealistic to have someone stay with the client at all times or for the client to stay in bed until the nurse can assist. Using side rails creates unnecessary barriers and may be a safety hazard.

The nurse is preparing to suction a tracheostomy for a client with methicillin-resistant Staphylococcus aureus (MRSA) (see figure). What should the nurse do next?

Proceed to suction the client's tracheostomy. The nurse is wearing protective personnel equipment appropriate for suctioning the client: goggles, gown, and respirator mask. It is not necessary to wear a PAPR face shield to suction a tracheostomy. A surgical mask does not provide maximum protection.

A nurse realizes that data has been entered on the wrong client's written health record. Which step should the nurse take to correct this documentation error?

Put a line through the entry, leaving the content visible, and initial. The nurse should put a line through the incorrect entry, leaving the original entry visible, and then sign the entry. The other options are incorrect and do not follow nursing documentation standards.

A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement?

Related to impaired balance A client with a cerebellar brain tumor may suffer injury from impaired balance as well as disturbed gait and incoordination. Visual field deficits, difficulty swallowing, and psychomotor seizures may result from dysfunction of the pituitary gland, pons, occipital lobe, parietal lobe, or temporal lobe — not from a cerebellar brain tumor. Difficulty swallowing suggests medullary dysfunction. Psychomotor seizures suggest temporal lobe dysfunction.

An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. What should the nurse advise the mother to do?

Remove any unsafe items from the area in which the infant is mobile. Safety is the priority in caring for this infant. Infants adapt easily, increasing mobility even with a splint in place. Therefore, the mother needs to ensure that the area in which the infant is mobile is safe. There is no need to contact the HCP to alter the treatment plan. Confining the infant to one room may not allow the child to achieve normal development. The child needs different environments for maximum development. The infant needs to wear the splint as prescribed by the HCP to ensure optimal healing.

A psychiatric treatment team is planning care for a client who was involuntarily admitted for treatment of depression and suicide ideation. When planning the client's care, what legal parameters of care should the nurse be aware of?

The client is able to refuse medications. Competent clients have the right to refuse medications. Even though the client is an involuntary admission, the client is competent and able to be involved in treatment planning. Because the client was admitted involuntarily, the client is not able to obtain release. The client who is legally declared incompetent is given a court-appointed guardian or representative who is responsible for giving consent. A client is considered to be competent unless the court has declared that the client is incompetent. The client who is incompetent is not able to give or refuse consent for treatment.

A client is being assessed for multiple lacerations resulting from an assault by an unknown paid sexual partner. The nurse must recognize what as a priority for this client?

The client's safety should be provided in a secure and private environment. Regardless of the gender of the client or the attacker, a traumatic assault demands that safety and security are a top priority. The client may resist filing a police report because of the paid sex (prostitution), and because it was with a stranger. Testing for sexually transmitted diseases is not a priority until the wounds have been treated. The client's illicit behavior does not warrant being referred to a community free clinic.

A client with acute bronchitis is admitted to the healthcare facility and is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the most likely cause of this sound?

The oxygen tubing is pinched. Pinching of the tubing used to deliver oxygen causes a high-pitched whistling sound. When the water level in the humidifier reservoir is too low, the oxygen tubing appears dry but doesn't make noise. A client with a nasal obstruction becomes more uncomfortable with nasal prongs in place and doesn't experience relief from oxygen therapy; the client's complaints, not an abnormal sound, would alert the nurse to this problem. A nasal cannula can't deliver oxygen concentrations above 44%.

The nurse is applying a hand mitt restraint for a client with pruritus (see figure). What should the nurse do first?

Verify the prescription to use the restraint. Before using any restraints, the nurse must verify that a health care provider (HCP) has written a prescription for the restraint. The mitt does not need to be secured with ties. The client can move the hand as needed. It is not necessary to place a pillow under the wrist. The nurse should place the mitt on the palmar surface of the hand.

The nurse assists the client to the operating room table and supervises the operating room technician preparing the sterile field. Which action, completed by the surgical technician, indicates to the nurse that a sterile field has been contaminated?

Wetness in the sterile cloth on top of the nonsterile table has been noted. Moisture outside the sterile package contaminates the sterile field because fluid can be wicked into the sterile field. Bacteria tend to settle, so there is less contamination above waist level and away from the technician. The outer inch of the drape is considered contaminated but does not indicate that the sterile field itself has been contaminated.

When caring for the client with hepatitis B, which situation would expose the nurse to the virus?

a blood splash into the nurse's eyes Hepatitis B virus is spread through contact with blood, body fluids contaminated with blood, and such body fluids as cerebrospinal, pleural, peritoneal, and synovial fluids; semen; and vaginal secretions. The risk of transmission of hepatitis B through feces is low. Touching the client without gloves is acceptable when there is no danger of contact with blood or body fluids. Recapping a used needle is a common source of needlestick injuries; needles should be properly disposed of uncapped.

A nurse should question an order for a heating pad for a client who has

active bleeding. Heat application increases blood flow and therefore is contraindicated in active bleeding. For the same reason, however, applying heat to a reddened abscess, an edematous lower leg, or a wound with purulent drainage promotes healing.

A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require?

contact A client with rabies requires contact isolation because the disease is highly transmissible through close or direct contact. Rabies isn't transmitted through the air, eliminating the need for strict isolation, which aims to prevent transmission of highly contagious or virulent infections spread by both air and contact. Respiratory isolation, which prevents transmission only through the air, isn't sufficient for a client with rabies. Enteric isolation is inappropriate because rabies isn't transmitted through direct or indirect contact with feces.

A client is admitted to the acute psychiatric care unit after 2 weeks of increasingly erratic behavior. The client is unkempt, has lost approximately 9 lb (4 kg), has been sleeping poorly, and exhibits hyperactivity. The client loudly denies the need for hospitalization. What priority intervention will the nurse apply?

decreasing environmental stimulation This client is at increased risk for injuring self or others. Decreasing environmental stimulation, a measure the nurse may take independently, may reduce the client's hyperactivity. Providing adequate hygiene is an appropriate nursing intervention but isn't the highest priority. Because the overall goal is to reduce the client's hyperactivity, orientating him to unit activities is contraindicated. Asking the client to go eat a meal in the day room is contraindicated because there is risk for harm to self or others and it is likely there will be more stimulation in the day room.

The children of an elderly client who has suffered an ischemic stroke have informed the nurse that an herbalist will be coming to their parent's bedside tomorrow to make recommendations for client's care. Which considerations should the nurse prioritize in light of the practitioner's planned visit?

ensuring any complementary therapies are safe when combined with his prescribed therapy While it is important for the nurse and the other members of the care team to ensure that stereotypes or cultural imposition do not exist, the priority in all aspects of care is safety. Consequently, potential interactions between the complementary therapies and conventional hospital treatments are a priority. The family should not be required to forgo conventional treatment to pursue some aspects of culturally based, complementary care.

Which prescription is entered correctly on the medical record?

fentanyl 50 mcg given IV every 2 hours as needed for pain greater than 6/10 Prescriptions should be written clearly to avoid confusion or misinterpretation. Clearly written prescriptions do not use a "trailing" zero (a zero following a decimal point) and do use a "leading" zero (a zero preceding a decimal point). Additionally, the prescribed medication should be written in full and avoid abbreviations of the drug and the dosage, for example "morphine sulfate" (avoiding use of "MS"), "ml" instead of "cc," and "micrograms" instead of "mcg."

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

manual resuscitation bag The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.

Which nursing intervention is the highest priority when a client is placed in restraints?

monitoring the client every 15 minutes Safety of the client and staff is the utmost priority. Therefore, the client must be monitored closely and frequently, such as every 15 minutes, to ensure that the client is safe and free from injury. Assisting with nutrition and elimination, performing range-of-motion exercises on each limb, and changing the client's position every 2 hours are important after the safety of the client and staff is ensured by close, frequent monitoring.

To prevent the spread of infection in the home healthcare environment, the nurse should follow appropriate technique by

placing equipment back on a liner when setting it down in the client's home. To prevent the spread of infection, nurses should use appropriate technique when handling their equipment bags by performing hand hygiene before reaching into the bag for supplies, cleaning any equipment removed from the bag before returning it to the bag, and placing the bag on a liner when setting it down in the client's home. Donning gloves, a mask, or gown when greeting the client or family members is not necessary and will interfere with the greeting process.

A nurse is performing a sterile dressing change. Which action contaminates the sterile field?

pouring solution onto a sterile field cloth Pouring solution onto a sterile field cloth contaminates the sterile field because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. Holding sterile objects above the waist, leaving a 1″ edge around the sterile field, and opening the outermost flap of a sterile package away from the body maintain the sterile field.

After an infant undergoes surgical repair of a cleft lip, the physician orders elbow restraints. For this infant, the postoperative care plan should include which nursing action?

removing the restraints every 2 hours Removing one elbow restraint at a time every 2 hours for about 5 minutes allows exercise of the arms and inspection for skin irritation. To prevent the infant from touching and disrupting the suture line, the nurse should use the restraints when the infant is asleep and awake. The nurse should maintain the elbow restraints from the time the infant recovers from anesthesia until the suture line is healed.

A new nurse is asked to start an I.V. on an antepartum client. The new nurse has performed the procedure only once and isn't familiar with the I.V. pumps used in this facility. The new nurse should:

review the unit's procedure manual. A nurse should always refer to a policy and procedure manual for instructions on correctly performing a procedure. Asking another new nurse for assistance or attempting to perform an unfamiliar procedure without the necessary information makes the new nurse liable for errors that occur. A nurse who tells a client that she isn't experienced decreases that client's confidence in the nurse's credibility.

When the client is involuntarily committed to a hospital because the client is assessed as being dangerous to himself or others, which client rights are lost?

the right to leave the hospital against medical advice When a client is committed involuntarily, the right to leave against medical advice is forfeited. All the other rights are preserved unless there is further court action or a case of imminent danger to self or others (hitting staff, cutting self).

The nurse administers a medication by the intramuscular route to a client. Which action would put the nurse most at risk for a needlestick injury?

using one-handed needle recapping immediately after administration A nurse should use the one-handed needle-recapping technique only when absolutely necessary, such as when a sharps disposal container isn't readily available. A sharps disposal container is available in most instances. Nurses shouldn't recap needles. Choosing safety needle devices whenever possible and appropriate; planning in advance how to handle and dispose of needles; and discarding needles, safety needle systems, and sharps in sharps disposal containers immediately after use are safe ways to handle sharps with less risk of needlestick injuries.

A client with Alzheimer's disease is being treated for malnutrition and dehydration. The nurse decides to place them closer to the nurses' station because of their tendency to

wander A client with Alzheimer's disease is at risk for injury because of their tendency to wander. Placing them closer to the nurses' station makes it easier to monitor them and better ensures their safety if the client begins to wander. Placing the client closer to the nurses' station won't help the client remember to eat, change position often, or modify their behavior.

A 15-year-old adolescent confides in the nurse that the adolescent has been contemplating suicide. The adolescent has developed a specific plan to carry it out and pleads with the nurse not to tell anyone. What is the nurse's best response?

"For your protection, I can't keep this secret. After I notify the physician, we will need to involve your family. We want you to be safe." In situations in which a client is a threat to self, the nurse can't honor confidentiality. Because this adolescent has a specific plan to commit suicide, the nurse must take immediate action to ensure the adolescent's safety. The physician and mental health professionals should be notified as well as the client's family. The nurse should inform the adolescent that this is necessary, while at the same time conveying a sense of caring and understanding. The local authorities needn't be notified in this situation.

When planning care for a client who has ingested phencyclidine (PCP), the nurse's highest priority should be meeting the client's:

safety needs. The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as those of the staff. Drug effects are unpredictable and prolonged, and the client may easily become aggressive and physically violent. After safety needs have been met, the client's physical, psychosocial, and medical needs may be addressed.

A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission by saying:

"I'll stop being contagious when I have a negative acid-fast bacilli test." A client with drug-resistant tuberculosis is not contagious when the client has had a negative acid-fast test. A client with nonresistant tuberculosis is no longer considered contagious when there is clinical evidence of decreased infection, such as significantly decreased coughing and fewer organisms on sputum smears. The medication may not produce a negative acid-fast test result for several days. The client will not have a clear chest X-ray for several months after starting treatment. Night sweats are a sign of tuberculosis, but they do not indicate whether the client is contagious.

A postmenopausal client is scheduled for a bone density scan. What should the nurse instruct the client to do?

Remove all metal objects on the day of the scan. Metal will interfere with the test. Metallic objects within the examination field, such as jewelry, earrings, and dental amalgams, may inhibit organ visualization and can produce unclear images. Ingesting foods and beverages days before the test will not affect bone mineral status. Short-term calcium gluconate intake will also not influence bone mineral status. The client may already have had chronic pain as a result of a bone fracture or from osteoporosis.

he mother of a client who has a radium implant asks why so many nurses are involved in her daughter's care. She states, "The doctor said I can be in the room for up to 2 hours each day, but the nurses say they are restricted to being here for 30 minutes." What should the nurse explain to the client? Nurses:

work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. The three factors related to radiation safety are time, distance, and shielding. Nurses on radiation oncology units work with radiation frequently and so must limit their contact. Nurses are physically closer to clients than are visitors, who are often asked to sit 6 feet (182.9 cm) away from the client. Touching the client does not increase the amount of radiation exposure. Aseptic technique and isolation prevent the spread of infection. Age is a risk factor for people in their reproductive years.

A nursing instructor is instructing a group of new nursing students. The instructor reviews that surgical asepsis will be used for which procedure?

IV catheter insertion Caregivers must use surgical asepsis when performing wound care or any procedure that involves entering a sterile body cavity or breaking skin integrity. To achieve surgical asepsis, objects must be sterilized or kept free of all pathogens. Because inserting an IV catheter disrupts skin integrity and involves entry into a sterile cavity (a vein), surgical asepsis is required. Medical asepsis is used when instilling eye drops. The GI tract isn't sterile; therefore, irrigating a nasogastric tube or a colostomy requires only clean technique.

A nurse assists in writing a community plan for responding to a bioterrorism threat or attack. When reviewing the plan, the director of emergency operations should have the nurse correct which intervention?

Clients exposed to anthrax should immediately remove contaminated clothing and place it in the hamper. Clients exposed to anthrax should place contaminated clothes in a plastic bag and mark the bag "contaminated." Wearing protective clothing, instructing exposed clients to wash thoroughly, and restricting access to the exposed area are appropriate actions to take in response to a bioterrorism threat.

After the discharge of a client from a surgical unit, the housekeeper brings a blue pill to the nurse. The pill was found in the sheets when the linens were removed from the client's bed. The nurse reviews the client's medication administration record, which shows that the client received this medication at 0800. What would be the nurse's priority action?

Complete an incident form and notify the physician. This is a medication error. The nurse must document the error so the cause of the error can be identified and a plan put in place so it does not happen again. The nurse should notify the physician so the physician can determine whether the client needs to be contacted with follow-up instructions. The other options are incorrect, as they do not follow agency policy or nursing professional standards for medication administration.

Which action by the nursing assistant would require immediate intervention by the nurse?

restraining a school-age child at risk for self-harm because the nursing assistant had to leave the room The nurse supervising a nursing assistant will need to intervene when a nursing assistant restrains a client requiring one-on-one observation to leave the room. It should be reinforced with the nursing assistant to call for a replacement for the time needed to leave the client. Assisting a preschooler in a bathroom is appropriate for that age group. Transporting an infant in a bassinet is appropriate and within the scope of the nursing assistant's job. Removing the toddler from the mother's bed to the crib is appropriate. Cosleeping is dangerous for the child, and the mother should be educated on the risks.

Which precautions should the health care team observe when caring for clients with hepatitis A?

wearing gloves when giving direct care Contact precautions are recommended for clients with hepatitis A. This includes wearing gloves for direct care. A gown is not required unless substantial contact with the client is anticipated. It is not necessary to wear a mask. The client does not need a private room unless incontinent of stool.

When assisting a client use a cane, the height of the cane should be around the level of the hip joint so that the elbow joint is flexed at 30 degrees. The cane is held on the stronger side of the body. The cane is advanced first, followed by the weak leg. The strong leg is not advanced after advancing the cane. The cane and strong leg are not advanced together.

wears a gown and gloves while caring for the client. Caring for a client infected with vancomycin-resistant enterococci requires contact precautions. The nurse should wear a gown and gloves. Protective eyeware is not required for contact precautions. Gloves are most contaminated, so the nurse should remove them first when exiting the room to prevent infection transmission. The nurse should assemble all needed supplies before putting on personal protective equipment and entering the client's room.

A nurse is teaching the proper use of crutches to a school-age child with a femur fracture with no weight bearing. What will the nurse include with teaching about walking with crutches?

"After advancing both crutches the length of one step, move your 'good' leg forward." When walking with crutches, a child should be instructed to advance both crutches, then advance the unaffected leg. The unaffected leg then supports much of the weight associated with ambulation. It will not be effective to move the affected leg forward first. It wouldn't be safe for the child to advance only one crutch.

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

Check the equipment. A reading of 0 mm Hg indicates equipment malfunction. The nurse should check the equipment and report problems. Normal and stable ICP values are less than 15 mm Hg. Some pressure is always present in the cranial vault. The nurse shouldn't contact the physician to review the care plan at this time. The nurse needs to complete the assessment of the client and equipment before making a report to the physician.

When assessing a hospitalized client diagnosed with Major Depression and Borderline Personality Disorder, the nurse should ask the client about which of the following first?

Suicidal thoughts. The nurse should first determine if the client is suicidal. If the client is suicidal, it is crucial to know what the client plans to do. The seriousness of intent to die would determine the level of suicidal precautions required to maintain safety. Understanding about access to means for suicide is more important as the client is preparing for discharge.

The nurse is required initially to restrain all four of a client's extremities. For what reason would the nurse anticipate the need to add a full-length restraint blanket?

The client is at risk for injury from fighting the restraints. A full-length restraint blanket is added when the client is at risk for injury from fighting the restraints. The increased degree of restriction is justified only when the risk of client injury increases. Feeling more secure is not a sufficient cause for using a more restrictive measure. Client statements that restraints are tight and uncomfortable require the nurse to assess the situation and adjust the restraints if necessary to ensure adequate circulation. Four-way restraints already provide adequate protection for the staff.

A nurse is working on a labor and delivery unit that requires all visitors to pass a screening protocol prior to entry. What is the nurse's priority action when a person gains access to the unit after bypassing the screening protocol?

Stop the visitor, and ask for identification. Labor and delivery units are locked to prevent neonate abduction. All visitors should be stopped at the door, identified, and matched to a current client. If an unidentified visitor gains entry without having gone through this process, it is appropriate to stop the person to ask for identification and confirm who the visitor is there to see. Calling security, making sure that each neonate is with its parent and noting the time and a description of the individual would not be the priority actions in this case; but rather what one would do for an attempted abduction.

The nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first?

Increase the frequency of client observation. The first intervention for a confused client is to increase the frequency of observation, moving the client closer to the nurses' station if possible and/or delegating the unlicensed assistive personnel (UAP) to check on the client more frequently. If the family is able to stay with the client, that is an option, but it is the nurse's responsibility, not the family's, to keep the client safe. Wrist restraints are not used simply because a client is confused; there is no mention of this client pulling at intravenous lines, which is one of the main reasons to use wrist restraints. Administering a sedative simply because a client is confused is not appropriate nursing care and may actually potentiate the problem.

The unlicensed assistive personnel (UAP) records a capillary blood glucose of 253 mg/dL (14.04 mmol/L) and the nurse administered insulin for coverage to the client. The UAP reports to the nurse that the blood glucose was incorrect. What actions should the nurse take? Select all that apply.

Obtain a current blood glucose level. Observe the client for hypoglycemia. Report the incident to the healthcare provider. Complete an incident report. The nurse should obtain a current blood glucose level to ascertain whether the blood glucose level is higher or lower than the amount stated, and this will guide the nurse in correcting the error. Observe for hypoglycemia because the nurse administered insulin to the client and the client's blood glucose may drop drastically. Report the incident to the healthcare provider so an order can be given, and complete an incident report recounting the incident. Reprimanding the UAP for the incorrect blood glucose will not correct the incident.

A client lives in a group home and visits the community mental health center regularly. During one visit with the nurse, the client states, "The voices are telling me to hurt myself again." Which question by the nurse is most important to ask?

"Are you going to hurt yourself?" The nurse needs to ask the client whether he is going to hurt himself to determine the client's ability to cope with the voices and to assess the client's impulse control. The nurse's assessment will then determine the course of action to take regarding the client's safety. Asking when the client hears the voices and how long the client has heard them is important but not as important as determining whether the client will act on what the voices are saying. Asking, "Why are the voices starting again?" would be inappropriate because the client may not know why and may not be able to answer the nurse.

What should a nurse do to ensure a safe hospital environment for a toddler?

Move the equipment out of reach. Moving the equipment out of reach ensures a safe environment because toddlers are curious and may try to play with items within their reach. Toddlers in a strange hospital environment still need the security of a crib. Stacking toys don't need to be moved out of reach because they don't present a safety hazard and are appropriate for this age-group. Padded crib rails are necessary only if seizure activity is present.

A nurse is caring for a client with a history of falls. The nurse's first priority when caring for a client at risk for falls is

keeping the bed in the lowest possible position. Keeping the bed at the lowest possible position is the first priority for clients at risk for falling. The call light should be placed so that it is easily accessible. Instructing the client not to get out of bed may not effectively prevent falls — for example, if the client is confused. Even when the client needs assistance to get out of bed, the nurse should place the bed in the lowest position. The client may not require a bedpan.

The nurse needs to pick up a large object that is sitting on the floor in a client's room. Which action most increases the nurse's risk of a back injury?

leaning forward toward the object Leaning forward causes the line of gravity to fall outside the base, encouraging the development of a back injury. Actions to reduce the development of a back injury include moving close to the object, using the large muscles of the arms and legs to lift the object, and bringing the body close to the level of the object.

The nurse is caring for a client after surgery. The surgeon has written "resume pre-op meds" as an order on a client's chart. What should the nurse do next?

Contact the surgeon for clarification because this is not a complete order. After surgery, all orders must be renewed as full orders. This requires complete orders, including the drug name, route, dose, frequency, and reason for administration (e.g., pain). The other options are incorrect because the most responsible physician needs to order interventions that are relevant to the postoperative client. Preoperative orders may contain orders that are not relevant postoperatively and would cause harm to the client. The other options could put the client at risk and the nurse in a position of negligence.

The nurse is caring for a client recently diagnosed with hepatitis C. In reviewing the client's history, what information will be most helpful as the nurse develops a teaching plan? The client:

has a known history of sexually transmitted disease. Although primarily bloodborne, unprotected sex with multiple partners and/or a history of sexually transmitted disease are risk factors for transmission of the hepatitis C virus. Other risk factors include blood transfusions, past treatment with chronic hemodialysis, being a child born to women infected with hepatitis C virus, past/current illicit IV drug use or needle-stick injuries to healthcare workers. It is important for the nurse to be aware of the client's history in order to help determine the client's level of understanding of the disease, promote a healthy lifestyle, and discuss the role of viral transmission of the disease.