ADN 140 - PrepU - Safe Practice 2

The nurse is caring for a client who is in contact isolation for an infection. The client informs the nurse that a shaman will be coming to visit and asks for privacy during that time. The most appropriate response from the nurse will be which of the following?

"When the shaman arrives I will help him with the personal protective equipment he will need.

You are caring for a patient who has an infection spread by respiratory droplets and is in Droplet Precautions. The patient asks, "Can my spouse visit me?" Which of the following responses is correct?

"Yes, as long as your spouse wears a mask and stays at least 3 feet away from you.

A nurse is caring for a client who is disoriented to time, place, and person and is attempting to get out of bed and pull out an intravenous line. The nurse receives orders from a health care provider to apply a vest restraint and bilateral soft wrist restraints. In carrying out this order, which nursing actions would be appropriate? Select all that apply. - Perform a face-to-face behavior evaluation every hour. - Tie the restraints in quick-release knots. - Tie the restraints to the side rails of the bed. - Document the client's condition. - Document alternative methods used before the restraints were applied. - Document the client's response to the intervention.

- Perform a face-to-face behavior evaluation every hour. - Tie the restraints in quick-release knots. - Document the client's condition. - Document alternative methods used before the restraints were applied. - Document the client's response to the intervention.

A client is admitted on the day of surgery for arthroscopy of the left knee. Which nursing action(s) should be completed prior to administering anesthesia to the client to avoid wrong-site surgery? Select all that apply. - Verify that the surgeon has marked with a permanent marker the correct knee for the surgical site. - Ask the client to state their name, surgical site, and procedure. - Verify the correct client with the correct operative site from medical records and diagnostic reports. - Call a "time-out" in the operating room to have the surgeon verify the correct knee before making the incision. - Show the client an anatomic model of the surgery site.

- Verify that the surgeon has marked with a permanent marker the correct knee for the surgical site. - Ask the client to state their name, surgical site, and procedure. - Verify the correct client with the correct operative site from medical records and diagnostic reports. - Call a "time-out" in the operating room to have the surgeon verify the correct knee before making the incision.

A client newly diagnosed with tuberculosis (TB) is being admitted with a prescription for "isolation precautions for tuberculosis." The nurse should assign the client to which type of room?

A private room to implement airborne precautions.

Surgical asepsis is defined as

Absence of all microorganisms.

Many orthopedic-related injuries occur while participating in sports or in the workplace. Elements of client and family teaching aiming at prevention include which of the following?

All options are correct.

A nurse is administering an anti-hypertensive drug to a hospitalized patient. What action should the nurse take to identify the patient prior to administration?

Check the patient's ID bracelet.

You are reviewing a patient's newly written medication order and are unable to read the prescriber's handwriting. Which of the following actions by the nurse is most appropriate?

Contact the prescriber to clarify the order.

A client with an infected abdominal wound must be placed on contact precautions for 10 days. What should the nurse do to help meet the client's emotional needs?

Describe why the client is on contact precautions and what will occur there, and reassure the client.

The primary reason for lubricating the urinary catheter generously before inserting the catheter into a male client is to prevent which problem?

Friction along the urethra when the catheter is being inserted.

A student nurse is performing a urinary catheterization for the first tine and inadvertently contaminates the catheter by touching the bed linens. What should the nurse do to maintain surgical asepsis for this procedure?

Gather new sterile supplies and start over.

Which nursing action is a component of medical asepsis?

Hand washing after removing gloves.

A nurse is adding a sterile solution to a sterile field and has just opened the bottle according to manufacturer's directions. What is the next step?

Hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a heigh of 4 to 6 inches.

Mental health laws in each state specify when restraints may be used and which type of restraints may be used. Most law stipulate that restraints may be used:

If a client poses a present danger to himself or others.

Which of the following statements best explains the rationale for bringing an extra pair of sterile gloves into an adult patient's room before preparing for a sterile procedure?

If the first pair is contaminated and needs to be replaced, the nurse does not need to leave the room for a new pair.

The nurse understands that the purpose of the "time out" is to:

Maintain the safety of the client.

The nurse is caring for a client with Clostridium difficile infection. Upon entering the room, which of the following steps should the nurse take?

Put on an isolation gown and gloves.

After an infant undergoes surgical repair of the 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.

A client is being sent home with oxygen therapy. The nurse instructs that

Smoking or flame is dangerous near oxygen.

A staff development nurse is discussing techniques to prevent back injury with a group of nursing assistants. The nurse informs the group that back stress and injury can be prevented by doing which of the following?

Spreading feet shoulder-width apart to broaden the base of support.

A nurse is performing a venipuncture on a patient and notices that there is a hole in one of the sterile gloves. What would be the appropriate action to take to maintain a sterile field?

Stop the procedure, remove damaged gloves, perform hand washing, and open new sterile gloves.

The nurse planning to insert an indwelling urinary catheter into a client should utilize which of the following techniques?

Surgical asepsis.

While observing a new nurse inserting an indwelling urinary catheter, the preceptor observes a break in sterile technique. What is the preceptor's best first action?

Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped.

A nurse preceptor is observing a new graduate during care of a client in contact isolation. Which action by the new graduate indicates a need for further teaching about handling infectious materials?

The nurse uses alcohol gel to clean her hands after changing linen soiled with urine and feces.

The nurse in the pediatric unit for a 10-year-old boy admitted with dehydration and diarrhea after eating chicken contaminated with Salmonella bacteria. What action taken by the nurse would be the most effective in preventing the spread of the infectious microorganism?

Washing hands before and after providing client care.

A patient is placed in isolation for suspected tuberculosis. Which of the following actions should the nurse take when entering the patient's room?

Wear an N-95 respirator.