NCLEX questions
The nurse is teaching a group of clients at the community center about burn prevention for children. Which of the following should be included in the teaching?
-A "The handles of the pots on the stove must be turned inward." Correct Answer B "The hot water tank should be set at 150 degrees." C "Infants can be bathed in the kitchen sink." D "Electrical outlets do not need to be covered until the infant is crawling." Rationale: Turning the handles in will limit the risk of the child reaching up and pulling a hot pot onto themselves. Hot water tanks should be set at 120 degrees or less to decrease likelihood of scalding. Bathing in the sink increases the risk that the infant will turn the hot water on. Electrical outlets should be covered to prevent anything from being inserted into it.
The nurse is planning care for a client who is paralyzed on the right side. Where should the nurse place the signaling device? A On the left side of the bed near the client's hand B Near the pillow on the right side C Across the client's chest D Attached to the bed
A Any items the client needs to use must be place on the unaffected side. Placing them anywhere else or on the affected or paralyzed side will not allow the client to use them. Attaching the signaling device to the bed may be out of reach for the client.
The home health nurse is assessing a client's home for safety hazards. Which finding observed by the nurse would increase the client's risk for carbon monoxide poisoning? A Client uses a wood-burning stove to heat the home. B Client keeps their electric car stored in the garage. C Client keeps a charcoal grill for cooking on the back patio. D Client has a gasoline powered lawnmower stored in an outdoor shed.
A Rationale: Carbon monoxide is an odorless, colorless gas that is toxic, and prolonged exposure can lead to brain damage or death. Risk factors for carbon monoxide poisoning include using gasoline-powered vehicles, lawnmowers, barbeques, and wood-burning units or stoves inside the home; therefore, a wood-burning stove places the client at an increased risk. The risk for carbon monoxide poisoning is reduced if these units are not in use in enclosed spaces.
The nurse is providing teaching about car seats to the parents of a 30-pound child. Which of the following should be included in the teaching?
A "The buckled chest clip should be 1 inch below the armpit level of the child." B "A child can safely ride in the front seat while in a booster seat." -C "The child can be placed in a forward-facing car seat with a harness." D "The car seat can move side-to-side 1-2 inches after being secured." Rationale: A child of 30 pounds can sit in a forward-facing car seat or booster. The buckled clip needs to be at the armpit not below. Children cannot ride it the front seat, regardless of weight. All seats should be securely fastened and not be able to move at all.
A community health nurse is educating a group of clients on burn safety. Which client is at a higher risk for burns? A A client with peripheral arterial disease B A client with chronic kidney disease C A client with a traumatic brain injury D A client with diabetic nephropathy
A* Rationale: Clients with peripheral arterial disease have decreased blood flow and sensitivity to the lower extremities. Clients with decreased sensation to the feet can suffer burns without realizing the injury. Decreased sensation is not an expected finding for a client with chronic kidney disease. Clients with a traumatic brain injury are at a high risk for falls and seizures. Diabetic nephropathy is damage to the kidneys due to elevated blood glucose levels. Diabetic nephropathy does not result in decreased sensory perception.
A nurse attends a training on activation of the hospital incident command system (HICS). Which personnel role does the nurse identify as being responsible for rapidly evaluating clients to determine priorities for treatment? A Public information officer B Triage officer C Hospital incident commander D Charge nurse
B Rationale: A triage officer is responsible for evaluating clients and determining the priority for treatment. A public information officer is a person who serves as a liaison between the media and the hospital. The hospital incident commander is the person who assumes overall leadership when the emergency plan is implemented. The charge nurse is responsible for coordinating staff roles in the assigned unit.
The nurse has collected a stool specimen from a client with antibiotic associated diarrhea. Clostridium difficile is suspected. What action should the nurse take to transport the specimen to the lab?
*A Place the specimen in a small biohazard bag. Correct Answer B Wear gloves and an isolation gown when walking to the lab. C Wipe the exterior of the collection cup with a disinfectant wipe. D Place the client's label on the cap of the collection cup. Rationale: Personal protection equipment (PPE) should be removed inside or just outside of the client's room. It is not worn in the hallway. Send or transport the specimen to the laboratory in a biohazard bag immediately or within the optimal time from collection as indicated by facility policy and guidelines. Avoid contact with soaps, detergents, and disinfectants as these may affect test results. The identification label should be attached to the cup so that when the lid is removed, the specimen remains labeled.
A staff nurse is assisting the unit charge nurse with narcotic counts. The staff nurse notices the charge nurse becomes nervous when several discrepancies in the counts are found. Which action should the staff nurse take?
*A Stop the count and notify the unit manager. Correct Answer B Continue the count and offer therapeutic statements to the charge nurse. C Complete the count and document the discrepancies. Your Answer D Pause the count and find another staff nurse to assist the charge nurse. Rationale: It is the nurses' responsibility to report narcotic discrepancies and behaviors indicative of substance abuse. The nurse should stop the count and notify a supervisor. Offering therapeutic statements to the charge nurse does not address the behavior change when discrepancies are found. Completing the count makes the staff nurse liable for the discrepancies. Pausing the count and finding another staff nurse does not address the issue of the charge nurse's reaction to the discrepancies.
The infection control nurse is evaluating a staff member putting on personal protective equipment (PPE) before entering the room of a client who is on droplet isolation. Which item should the staff member put on first?
*A Gown B Mask Your Answer C Gloves D Face shield Rationale: When putting on PPE, the first item to put on is the gown, followed by the mask, face shield, and then gloves.
The nurse is reviewing the communicable disease policy about what information needs to be provided to the health department. Which statement by the nurse indicates the need for additional education about the policy?
A "The results of testing should be provided." B "I will need to report the onset of symptoms." *C "HIPAA prevents the reporting of personal information." D "Patient information such as name, age, and gender are reported." Rationale: This type of required reporting uses personal identifiers and enables the states to identify cases where immediate disease control and prevention are needed. Each state has its own laws and regulations defining what diseases are reportable. The list of reportable diseases varies among states and over time. HIPPA does not apply to reportable diseases.
The nurse is caring for a pediatric client who is experiencing a febrile seizure. Which action should the nurse take first?
A Administer anticonvulsant medication -B Protect the child's head from injury C Loosen any clothing around the neck D Apply a cooling blanket over the client Rationale: Protecting the child from injury would be the highest priority action. Seizure activity may cause the child to have involuntary movements which could result in hitting their head. Loosening the clothing will help maintain the airway but would not be done first. The cooling blanket can help reduce the fever but would not be done first. Administering anticonvulsant medication would not happen first.
A nurse is reviewing new prescriptions for a client with suspected meningitis. The client has a history of atrial fibrillation and is taking warfarin for disease management. Which prescription should the nurse clarify?
A CT scan of the head B Blood cultures *C Lumbar puncture D MRI of the spine Rationale: The nurse should clarify the lumbar puncture order. Clients who are on anticoagulant medications are at risk of bleeding. A lumbar puncture may cause bleeding that can compress the spinal cord. Obtaining a blood culture is not contraindicated in a client taking anticoagulant medications. The nurse should apply direct pressure after the venipuncture. A computerized tomography (CT) scan of the head and a magnetic resonance imagining (MRI) of the spine are not invasive and will not affect the client taking anticoagulants.
A charge nurse is assigning a room to a client with a history of moderate Alzheimer's. The charge nurse will assign the client to a room in which area of the unit?
A-Next to the client activity room B-At the end of the hallway C-In front of the elevator *D-Across from the medication room Rationale: Clients with moderate Alzheimer's may have personality and behavioral changes that lead them to wander and get lost. Medication rooms are frequently used by nurses. This placement ensures frequent visual checks of the client. Assigning the client to a room at the end of the hallway is not appropriate. Most stairwells are at the end of hallways and can be an area for the client to escape. A room in front of the elevator is not appropriate for a client with Alzheimer's. Assigning the client next to an activity room provides overstimulation. Noise should be kept to a minimum.
The nurse is instructing a group of unlicensed assistive personal in the correct use of personal protective equipment. Which statement by the UAP indicates understanding of the correct protocol? A "I only need to wear a mask during influenza season." B "I will wear gloves when performing hygiene care." C "I should wear a personal protective gown when assisting with meals." D "I have to put on the protective equipment when entering the room."
B Rationale: Gloves should be worn for all contact with blood and body fluids, nonintact skin, and mucous membranes for handling soiled items during hygiene care. Masks are worn when exposed to airborne and droplet respiratory disorders, such as tuberculosis or Covid-19, and can be worn any time of year. Gowns should be worn during procedures that are likely to cause splashes of blood or body fluids. Protective equipment is put on before entering a room.
A nurse is preparing to assess a newly admitted client. Which action should the nurse take first? A Explains the purpose of the assessment. B Checks the client's wristband. C Obtains a health history. D Places the client in a supine position.
B Rationale: The nurse should ensure proper identification of the client before providing care. The client's wristband will confirm name, date of birth, and medical record number. Explaining the purpose of the assessment is important. However, the nurse should ensure care is being provided to the correct client. Obtaining a health history should precede a physical assessment. However, the nurse must ensure the health history is being obtained from the correct client. Placing the client in a supine position is not a priority action. The nurse must first identify the client.
The nurse is assessing a client for the risk of allergic reactions to products commonly used in the healthcare setting. Which of the following statements by the client requires follow-up? A "I have an air purifier in my home for allergies to pet dander." B "I take a daily antihistamine due to dust-mite allergies." C "I avoid eating bananas because they make me itchy." D "I have a family history of anaphylaxis due to bee stings."
C Rationale: Clients should be assessed for risk of allergic reactions to products commonly used in the healthcare setting, such as iodine, adhesive tape, and latex. A sign of allergic reaction includes itching after eating a product. Allergies to foods such as bananas, kiwis and avocados are known to also cause allergic reactions to latex in clients, therefore itching after ingesting bananas may indicate risk of allergic reaction to latex. Allergies to pet dander, dust mites and a family history of allergies to bee venom do not increase the client's risk of allergic reaction to common healthcare products.
The nurse is completing a home health visit for a client who uses a wheelchair. Which of the following findings indicate the need for home modification? A Low countertops in the bathrooms B A walk-in shower C Upper cabinets in the kitchen are empty D Uneven flooring in the home
D Rationale: For the client who uses a wheelchair, having uneven flooring can be a significant safety issue and modifications are warranted. Lowered countertops and walk-in style showers are both appropriate. Not utilizing the upper cabinets in the home may be appropriate and is not a safety concern.
A nurse walks into a client's room and hears the unlicensed assistive personnel (UAP) telling the client, "If you continue to use that call bell for no reason, I am going to restrain you." What action does the nurse take? A Reprimand the UAP in the client's room B Instruct the UAP to make frequent rounds on the client C Educate the UAP on the indication for restraints D Report the UAP's statement to the unit manager
D* Rationale: The statement made by the unlicensed assistive personnel (UAP) is considered assault. Threatening statements to a client should be reported to a supervisor. Reprimanding the UAP in the client's room is not professional behavior. Instructing the UAP to make frequent rounds on the client does not address the threatening statement. Educating the UAP on the use of restraints is indicated when medically necessary and does not address the threatening statement.
The nurse is providing staff education on reducing hospital acquired infections by eliminating potential reservoirs of infection. Which of the following statements should be included in the teaching?
*A "Client bedrails should be disinfected regularly using hospital approved wipes." B "It is a good idea to wear gloves when touching door handles." C "Documentation areas are cleaned less often than client rooms." D "Soiled linens should remain in the client's laundry bin until discharge." Rationale: Research has shown that one of the biggest reservoirs of infection is the client's bedrails. These must be thoroughly sterilized between patients. Gloves are a potential source of infection. If someone is wearing gloves and touches a reservoir then touches the door handle, the door handle becomes a reservoir. Clients, visitors, healthcare providers, and facility staff may touch door handles multiple times each day. Office supplies, computer mice, and keyboards are all potential sources of infection and need to be diligently cleaned. Linen bags should be brought directly to the soiled utility room.
The nursing supervisor is working in an acute care facility following an earthquake. The building has lost water supply and is on generator power. Which patients should the nursing supervisor evacuate first?
*A Ventilator dependent adults in the ICU B Ambulatory adults on the medical unit C Ambulatory children in the pediatric unit D Non-ventilator dependent adults in the ICU Rationale: Evacuation decisions after No Advanced Warning Events such as earthquakes are based on building integrity, infrastructure, and environmental factors. If there is a potential or immediate threat to staff or clients, an assessment must be made to immediately evacuate or wait and reassess. Once evacuation is determined, triage is based on the availability of critical resources. In this case, the loss of power and water makes movement of acutely ill clients the priority. The other clients may be evacuated subsequently.
The nurse is caring for a client who has an allergy to shellfish. Which of the following products should the nurse avoid when caring for this client?
-A Iodine B Chlorhexidine C Alcohol D Lidocaine Clients with shellfish allergies may have a cross-reaction with products that contain iodine, including Betadine. These products should be avoided to prevent an allergic reaction in the client.
The nurse has taught a client about measures to reduce the risk of repetitive stress injuries. Which of the following statements by the client indicates the need for further teaching?
A "Varying the types of sports that I play may reduce the risk of acquiring a repetitive stress injury." Your Answer B "I will limit the amount of time I use electrical tools each week to reduce repetitive vibration to my joints." *C "Frequent lifting of heavy objects will increase muscle strength and reduce my risk of repetitive stress injuries." Correct Answer D "I will ensure that I have running shoes with proper padding in the soles to reduce impact on the joints in my legs." Rationale: Repetitive stress injuries are caused by sports, occupations, and hobbies that cause repetitive motion, causing strain on the joints and tendons. Frequent lifting of heavy objects increases the risk of repetitive stress injuries and requires further teaching. Varying the types of sports that are played can reduce the risk of acquiring a stress injury due to using the same motion frequently when training often for one particular sport (i.e., tennis elbow). Clients that use electrical tools that vibrate either for hobbies or for work are at risk for injury and these tools should be limited, if possible. Proper padding in running shoes and allowing for rest each week will reduce the risk of running-related stress injuries.
The nurse is documenting an occurrence in which the nurse identified that the wrong site was marked by the surgeon prior to the procedure being performed. Which type of practice error should the nurse document as having occurred?
A An adverse event Your Answer *B A near-miss event Correct Answer C A sentinel event D A root cause analysis Rationale: A near-miss event is the identification of any event or situation that might have resulted in client harm, but the harm did not occur due to timely intervention by healthcare staff. The nurse should document the identification of the wrong surgical site marking prior to the actual surgery as a near-miss. Near-misses should be documented as they occur so that root cause analyses can be performed to identify human factors that could be avoided to prevent a similar situation from occurring. An adverse event and a sentinel event occur when actual harm or death is inflicted on a client due to healthcare errors.
The nurse is teaching the parents of a toddler-age client about protective measures to reduce the risk of unintentional poisoning at home. Which of the following actions, if identified by the parent, indicates the need for further teaching?
A Attaching plastic hooks to cabinet doors B Placing poison warning stickers on toxic substances *C Reusing empty containers to store different substances Correct Answer D Storing cleaning agents and medications in locked cabinets Rationale: It requires further teaching if the parent reuses empty containers to store different substances. All substances should be kept in their original containers in the event of unintentional ingestion to alert the poison control center. It indicates a correct understanding of protective measures if the parent attaches plastic hooks to cabinets to keep them securely closed, stores medications and cleaning agents in locked cabinets, and places poison warning stickers on toxic substances.
The nurse is caring for a client who is undergoing internal radiation therapy. Which of the following actions by the nurse is appropriate to ensure safety?
A Encouraging the client to ambulate in the hallway B Following airborne isolation precautions while in the client's room C Discarding any dislodged implants into a sharps container *D Prohibiting visitation from children Correct Answer Rationale: For the client undergoing internal radiation therapy, the nurse should prohibit visitation from children or pregnant individuals. The client should remain in their own private room during ambulation. Airborne precautions are not necessary, but radiation shielding protective equipment should be used. If an implant is dislodged, it should be discarded into a radiation safe container; sharps containers do not protect from radiation.
The charge nurse observes a staff nurse carrying soiled linen in the hallway from a client who is receiving chemotherapy. Which statement by the charge nurse would be most appropriate? A "Soiled linens should be held away from the body and placed in a linen cart or bag before leaving the room." B "Soiled linens should be left in the client's room to prevent the spread of biohazardous and infectious materials." C "Linens should be changed weekly to prevent exposure to cytotoxic agents." D "Linens should be held closely to reduce the risk of any biohazardous or infectious materials from becoming airborne."
A Rationale: Blood and body fluids are contaminated with cytotoxic drugs or metabolites for about 3 to 5 days after a dose. Therefore, the nurse should wear appropriate PPE when handling patients' clothing, bed linens, or excreta. Linens should be placed in a specially labeled linen cart or plastic bag before being taken to the soiled utility room. It is important that meticulous hygiene is administered to the patient undergoing chemotherapy to help prevent infection. Therefore, linens should be changed as needed. Linens should be held away from the body to prevent contamination of the nurse's clothing.
The occupational health nurse is teaching a client about measures to reduce the risk of carpal tunnel syndrome. Which of the following should the nurse include in the teaching? A "Geometrically designed keyboards may assist with reducing strain on your fingers and wrists." B "Lower your chair height so that your wrists are flexed." C "Take frequent breaks from keyboards to perform other finger motions." D "Stretch your fingers and wrists in the morning before work."
A Rationale: Carpal tunnel syndrome is the most common repetitive stress injury. Clients should be taught proper ergonomics to reduce the risk of developing carpal tunnel syndrome, including stretching wrists frequently during the day while at work and typing, adjusting the chair height so that elbows are at a 90-degree angle without flexion of the wrists. Clients should be taught to take frequent breaks from keyboards in addition to typing on keyboards found on cellphones and handheld devices. A geometrically designed keyboard may reduce strain on fingers and wrists as well as adjustable height desks to allow for alterations in positions throughout the day.
The nursing supervisor is working in a hospital that is in the path of a hurricane. Which client would be appropriate for immediate discharge? A The client with nondisplaced tibia fracture that has been immobilized B The client with lymphoma receiving induction IV chemotherapy C The client with heart failure who is receiving 8 liters of oxygen D The client who had an appendectomy with a paralytic ileus
A Rationale: Medically unstable and unpredictable critical care patients are not candidates for discharge. Stable clients who need assistance are the second priority and, therefore, not discharged until the lowest priority clients are discharged. Ambulatory clients who need no assistance are the first clients to be safely discharged and relocated. The lowest acuity client here is the tibia fracture as this injury does not require surgical intervention. Clients who are receiving high flow oxygen, IV medication, and experiencing complications should not be discharged.
A nurse attended a training session on how to use a powered stand-assist lift to transfer a client to a chair. Which action by the nurse indicates correct use of the device? A Places the sling under the client's arms B Instructs the client to place the feet on the ground C Holds the client's hands when standing D Manually turns the handle to lift the client
A Rationale: Placing the sling under the client's arms is a correct method. The sling should be placed around the client's back and under the arms to support the torso during lifting. The feet should be placed on the footrests of the lift to support the weight during transfers. The nurse should instruct the client to place the hands on the lift handles. The powered stand-assist lift is designed to lift the client without assistance from the nurse.
The nurse is walking a client to the bathroom who has a history of seizures. The client states "My vision seems to be distorted." What action should the nurse take first? A Return the client to bed B Take the client to the bathroom C Assess the client's medication history D Call the emergency response team
A Rationale: The patient is reporting signs and symptoms of an aura, which is a warning sign before a seizure. Returning the client to bed will reduce the likelihood of injury. Calling the response team and checking the history would not be the first actions. Continuing to the bathroom is not an appropriate action, as the client is experiencing difficulty with ambulation.
The nurse is performing client care in response to an external disaster in the community. Which of the following actions should the nurse take first? A Evaluate clients for airway patency and effectiveness of breathing B Assess clients for uncontrolled bleeding and apply pressure as indicated C Evaluate clients for disability and immobilize the cervical spine as indicated D Assess for exposure to hazardous materials and observe the client for injury
A Rationale: The primary survey during a disaster response is performed to detect life-threatening injuries, which consists of checking for airway-breathing-circulation, disability, exposure, and then facilitation of family. The nurse should first assess clients for airway patency and quality of breathing, followed by the other actions.
The nurse is adding sterile solution from an open container onto a prepared sterile field. Which action should the nurse take? A Pour the sterile solution from a height of five inches B Place the cap of the sterile solution on the table with edges down C Pour the sterile solution immediately after opening the container D Apply sterile gloves before opening the sterile solution container
A Rationale: When adding sterile solution to prepared sterile field, the nurse should maintain the sterility of the solution and the field by pouring the solution 4 to 6 inches above the sterile container. When using a sterile solution container that has been opened, the nurse should place the cap with edges up and pour out solution lipping the bottle edges before pouring the solution onto the sterile field. The nurse will apply sterile gloves after pouring the sterile solution to prevent contamination.
The charge nurse is observing a newly hired nurse assess the client's ability to ambulate while transferring from a supine position in bed. Which of the following actions by the newly hired nurse requires intervention? A Assisting the client to sit upright with legs dependent on side of bed for 10 seconds B Assessing for upper and lower extremity weakness prior to standing by the side of the bed C Assisting the client to stand by the side of the bed for at least 1 minute D Assessing the client for dizziness or a sudden increase in heart rate prior to ambulation
A Rationale: When assisting clients to transfer from a supine position to ambulate, clients should be moved slowly and closely monitored for orthostatic hypotension and any weakness. It requires intervention if the nurse has the client sit and dangle the legs for 10 seconds. Clients should sit at the side of the bed for at least 1 minute for assessment of possible dizziness or vital sign changes. It is correct for the nurse to assess for extremity weakness prior to attempting to stand, assisting the client to stand for at least 1 minute prior to ambulation, and to assess the client for dizziness.
The nurse is performing a dressing change for a client who has an abdominal wound healing by secondary intention. There is a moderate amount of sanguineous drainage on the old dressing. How should the nurse dispose of this dressing? A Place in the client's regular trash bin B Discard in a red biohazard waste bin C Flush the dressing down the client's toilet D Call environmental services to remove the waste
B Rationale: A red bag marked BIOHAZARD is used to dispose of trash that contains liquid or semiliquid blood or other potentially infective material (OPIM), trash contaminated with blood or OPIM that would release these substances if compressed, and trash that is caked with dried blood or OPIM and is capable of releasing these materials during handling. Therefore, it is inappropriate to place the dressing in the client's trash bin. Dressings are not flushed down the toilet. It is unnecessary to call environmental services for this task.
A nurse is providing education to a client with diabetes type 2 on using a blood glucose monitor at home. Which client statement indicates an understanding of the teaching?
A "I will keep the used lancets on the counter until I can dispose of them properly." B "I will do the quality control test every time I use the glucose monitor." C "I will place the test strips in a plastic bag when I travel." *D "I will write the date I opened the test strips on the container." Rationale: Expired test strips can produce inaccurate results. Writing the date on the bottle prevents test strips from being used beyond their expiration date. Quality control tests do not need to be performed every time the glucose monitor is used. The nurse should instruct the client to perform the quality control test as recommended by the device manufacturer. Test strips should be kept in their original container. Light and moisture can affect their functionality. Lancets should be disposed of immediately after use. Exposed lancets can cause a needlestick injury.
The nurse has attended a staff education conference about assessing for factors that impact a client's ability to ambulate. Which of the following statements by the nurse indicates a need for further teaching?
A "The length of time a client has been in bed may impact the ability to ambulate without assistance." *B "The client should be medicated right before they attempt to ambulate." C "Clients should be assessed for the ability to understand directions prior to attempting ambulation." D "Client's range-of-motion ability should be assessed prior to attempting ambulation." Rationale: Several factors influence a client's ability to balance and ambulate safely. It requires further teaching if the nurse states that narcotics will improve balance and safety. While it is important to address pain levels and ensure comfort prior to ambulation, several medications, such as narcotics, sedatives, and tranquilizers may cause drowsiness, dizziness, weakness, and orthostatic hypotension and can hinder the client's ability to walk safely. The length of time a client is in bed can cause weakness and impair ability to transfer and ambulate. Clients should be assessed for the ability to understand directions during ambulation with or without assistive devices to ensure safe transfers. Limitations in range-of-motion or lower extremity strength may hinder ability to balance and transfer and may require assistive devices as needed.
The nurse is caring for a pediatric client a new diagnosis of cancer. The parent appears to be quite angry and has made threats towards staff members. Which of the following actions will reduce the risk of workplace violence while maintaining a caring environment?
A Call security to stand outside the client's room. Your Answer B Ignore the parent's behavior while providing care. C Tell the parent that these feelings are inappropriate. D Remain close to the doorway when talking with the parent. Rationale: Remaining close to the doorway allows the nurse to leave the room for assistance in case the parent becomes physically violent. While security may be notified of the potential need for their assistance, standing outside the room is likely to increase the anger of the parent. Ignoring the parent's behavior or telling them it is inappropriate does not validate the feelings that they are experiencing and decreases the nurse's awareness of safety concerns.
The nurse is assessing an older adult client for risk factors associated with falls. Which of the following should the nurse identify as increasing the risk of falls?
A Having a history of urinary tract infections -B Taking an opioid analgesic for pain C Living in a home that has wall-to-wall carpeting D Taking a daily antiplatelet medication B Factors that increase the risk for falls in older adults include medication use such as opioid analgesics which can cause confusion and drowsiness, as well as diuretic use, which can cause orthostatic hypotension leading to dizziness. Antiplatelet medications are not associated with an increased fall risk, rather an increased bleeding risk. A history of a UTI will not increase the risk of falls, however, a current UTI with urinary frequency or urgency could increase an older adult client's risk of falls. Clients are at an increased risk of falls in houses with throw rugs, which could be tripping hazards.
The nurse is conducting a compliance survey to identify adherence to infection control practices. While observing handwashing, which of the following findings would require intervention? A Artificial nails are scrubbed using a brush for 30 seconds. B Handwashing occurs for at least 15 seconds. C Wrists are included in the washing. D Soap is rinsed off from the wrist down to the fingertips.
A* Rationale: A nurse with artificial nails may harbor a large number and variety of microbes under the nails. The CDC and WHO both have recommendations regarding the avoidance of artificial nails in healthcare settings. Handwashing should occur for at least 15 seconds, include the wrists, and rinse water proximal to distal.
The nurse is working in the newborn nursery when an unfamiliar person in scrubs comes to the nursery door and requests to bring a newborn to the parents' room. What action by the nurse is appropriate? A Verify the hospital identification badge B Call security to the unit immediately C Check with the parents to verify the request D Ask the person if they are in the float pool
A* Rationale: Each member of the hospital staff should have an identification badge clearly displayed. The nurse should look at the identification of anyone trying to transport a newborn as this is one way to prevent infant abduction. The individual may have legitimate reasons for being on the unit, so it is not appropriate to immediately call security, nor is it appropriate to take the person at their word.
The nurse is performing hand hygiene before providing care to a group of clients. The nurse should identify that the use of alcohol-based hand sanitizer would be contraindicated in which of the following clients? A The client with a positive Methicillin-resistant Staphylococcus aureus (MRSA) infection B The client receiving treatment for Clostridium difficile C The client who has a history of Mycobacterium tuberculosis D The client that developed a Escherichia coli urinary tract infection
B Rationale: Alcohol-based hand sanitizers are an alternate way to perform hand hygiene. However, the nurse should use soap and water when caring for clients with Clostridium difficile, which is a gram-positive, spore-forming bacteria that is not killed with alcohol. The nurse can use alcohol-based hand sanitizers with clients who have other nosocomial infections.
The nurse is providing teaching about car seats to a client who is a first-time parent to a premature infant. Which information should the nurse include in the teaching? A Use a convertible car seat with a covering B Select a car seat with less than 5 ½ inch distance from the crotch strap to the seat back C Choose a car seat that does not recline D Pick a car seat that has head padding built into the head rest
B Rationale: An infant-only car seat should be used for preterm infants since convertible car seats are designed for full-term infants. Use a car seat with a distance of fewer than 5½ inches from the crotch strap to the seatback. This reduces the potential for your baby to slump forward. Infants should be in car seats that recline to keep the airway open. No head padding is recommended since the padding may push the infant's head forward.
The nurse is planning care for a client with a diagnosis of cancer who has received the first dose of intravenous chemotherapy. Which type of precautions should the nurse implement for this client? A Place the client on contact isolation B Wear a gown and gloves when handling linens and body fluids C Place incontinence pads in the regular trash bin D Maintain a distance of at least 3 feet from the client
B Rationale: Chemotherapy drugs are present in the waste and body fluids of clients for 3 to 5 days after administration. Nurses involved in handling chemotherapeutic agents may be exposed to low doses of the agents by direct contact, inhalation, or ingestion. Therefore, PPE should be worn when handling the client's linens. Incontinence pads should be placed in chemotherapy waste bins. Distancing is required with radiation implants and not chemotherapy.
The nurse is assessing a client for allergies prior to a scheduled magnetic resonance image (MRI) with contrast. Which of the following statements by the client requires follow-up? A "I take a daily antihistamine for nasal congestion due to pet dander." B "I get itchy when I put iodized salt on my food." C "I had a reaction in the past when I received blood products." D "I have an air purifier in my bedroom for dust-mite allergies."
B Rationale: Clients who are undergoing diagnostic testing with contrast medium should be assessed for allergies to iodine-containing food such as shellfish, cabbage, kale, and iodized salt, which could cause an adverse reaction. Allergies to pet dander, dust mites, and a previous blood transfusion reaction do not place the client at an increased risk of an adverse reaction to the contrast medium.
The nurse is teaching a group of parents about measures to reduce the incidence of unintentional poisoning in toddlers. Which of the following statements by a parent indicates a need for further teaching? A "I will carefully evaluate the products my child's toys are made of to reduce the likelihood that they contain lead." B "I will keep houseplants on the ground to ensure they do not get knocked over and cause injury." C "I will never leave my child unsupervised around standing water sources." D "All household chemicals will be kept on a top shelf, out of reach from my child."
B Rationale: Major causes of unintentional injury in toddlers are accidental poisoning due to ingesting toxic substances, such as plants, chemicals, and medications. Additional causes include exposure to lead in toys, paint, and ceramic dishes as well as drowning. The nurse should follow up if the parent states that houseplants should be kept on the ground. Toddlers are curious and often stick objects in their mouths, including plants, which can sometimes be poisonous if ingested. Plants should be kept out of reach of toddlers.
The nurse is participating in the implementation of a hospital's disaster response plan. Which of the following indicates correct understanding of disaster planning? A All hospital staff must receive training on identifying signs of bioterrorism activities within the community. B All hospital staff must receive training on handling of hazardous materials and decontamination. C Annual drills are required and should include community-wide resources with a simulation of a large influx of clients. D The hospital pharmacy is required to stockpile antibiotics and nerve agent antidotes in the event of a bioterrorist attack.
C Rationale: All facilities are required to carry out internal and external disaster drills, one of which includes implementing community-wide resources and simulation of a large influx of clients in the event of a disaster. Typically, nurses, emergency department physicians and other medical providers are required to receive training on handling hazardous materials, decontamination and recognizing patterns of illness that indicate potential bioterrorism in the community. While it is ideal for pharmacies to stockpile antidotes to nerve agents and antibiotics, this is not a federal requirement, although resources are becoming more available for facility pharmacies to obtain these medications.
The nurse has attended a staff education conference about incident reporting. Which of the following statements by the nurse indicates a need for further teaching? A "An incident report should be submitted for a client who fell after receiving an opioid analgesic." B "Any type of medication error requires the submission of an incident report." C "An incident report should be submitted when a client has an allergic reaction to a newly prescribed antibiotic." D "Any time a prescription is written for the wrong client, an incident report should be submitted."
C Rationale: An incident report is an agency record of an accident or unusual occurrence in the healthcare setting, which can be used to help prevent future incidents or accidents. It is the correct understanding of incident reporting if the nurse states that a client fall, medication error, and an incorrect prescription that is written for a client require incident reports. These are all considered errors or adverse/preventable events and should be reported to identify strategies to reduce human error and adverse events in the future. Clients may have unknown allergies to certain medications, and this requires prompt treatment of the allergy depending on severity as well as documentation in the medical record of the allergy, however, this is not considered an actual accident that requires incident reporting.
The nurse is caring for a client with severe osteoarthritis. Which of the following home interventions should the nurse recommend to promote client safety? A Avoid the use of analgesics prior to activity. B Perform exercise regimen at the end of the day. C Use an assistive device for ambulation. D Increase intake of high calorie foods.
C Rationale: Assistive devices allow a client with severe osteoarthritis to ambulate safely. Strenuous activity such as exercise should be planned for times when the client is in the least amount of pain, often this is in the morning hours. Analgesics are recommended prior to periods of significant activity. Increasing caloric intake does improve the safety of a client with osteoarthritis.
The nurse is teaching a client about fire safety in the home. Which of the following statements by the client indicates the need for further teaching? A "I will change the batteries in smoke alarms on special days, such as the first of the year." B "I will keep my fire extinguishers in locations that are most prone to fires, such as the kitchen." C "In the event of a fire, I will open all the windows in my house." D "In the event of a fire, I will move through smoke-filled areas with my head as close to the floor as possible.
C Rationale: It requires further teaching if the client states that they will open all windows and doors during a fire. The client should be taught to contain the fire, if possible, by closing windows and doors, which deprives the fire of oxygen. It is correct for the client to change smoke alarm batteries annually and doing so routinely on a special day helps clients to remember to do so. Fire extinguishers should be kept in locations that are prone to fires, such as the kitchen or near grills. In the event of a fire, clients should move with their heads as close to the ground as possible to prevent smoke inhalation.
A nurse is providing care to a client with chronic constipation. The client is on neutropenic precautions. Which prescription should the nurse clarify? A High-fiber diet B Abdominal x-ray C Digital disimpaction D Ambulate ad lib
C Rationale: The nurse should clarify the prescription for digital removal of feces. Digital disimpaction can damage the mucosa along the rectal wall and increase the risk of infection. A client with neutropenia is immunosuppressed. A high-fiber diet is recommended for clients with chronic constipation and does not affect a client with neutropenia. An abdominal x-ray is not invasive and can help visualize blockage of the intestines. Ambulation increases peristalsis and is encouraged for clients with constipation. Ambulation is not contraindicated for a client with neutropenia.
The nurse educator is reviewing the policy about needlestick injuries with a group of staff nurses. Which action should the nurse take first following a needlestick from a contaminated needle? A Put the needle in a biohazard bag for testing B Report to the Emergency Department C Clean the site with soap and water D Make an appointment to see the healthcare provider
C Rationale: The puncture site and skin should be washed thoroughly with soap and water. Then the nurse should follow the next steps in the facility-specific protocol for when a needlestick occurs. Once the nurse has reported the incident to the supervisor, the nurse will be directed to seek immediate treatment.
The nurse is caring for a client with a history of falls. The nurse observes the client attempting to get out of bed unassisted. Which safety device should the nurse implement for this client? A Apply soft wrist restraints B Raise all bed side rails C Initiate a pressure bed alarm D Set up an enclosure tent
C Rationale: When planning care for a client with a history of falls who is observed attempting to get out of bed unassisted, the nurse should implement safety devices that prevent injury. Restraints, such as wrist restraints, enclosure tents, and side rails, are physical devices that can limit the client's movement. The nurse should attempt less restrictive safety devices, such as pressure bed alarms. A pressure bed alarm is a safety device that alerts staff if the client attempts to get out of bed.
The nurse is documenting an occurrence in which the incorrect mole was removed from a client's leg. Which type of practice error should the nurse document as having occurred? A A sentinel event B A near-miss event C A never-event D An unpreventable event
C* Rationale: The nurse should document the incorrect removal of a client's mole as a never-event. Never-events are defined by the Joint Commission as surgeries on the wrong body part, foreign objects placed in the client after surgery, and mismatched blood transfusions. A sentinel event is one in which serious injury or death occurred due to errors. A near-miss event is the identification of any event or situation that might have resulted in client harm, but the harm did not occur due to timely intervention by healthcare staff. An unpreventable event is one in which death or client injury would occur in the absence of a medical error.
A nurse is providing care to a client experiencing substance withdrawal. Which prescription by the healthcare provider requires clarification? A Implement seizure precautions. B Keep client NPO. C Initiate cardiac monitoring. D Ambulate ad lib.
D Clinical manifestations of substance withdrawal include tremors, irritability, and unsteady gait. These manifestations increase the risk for falls. A prescription for ambulation as desired requires clarification. Substance withdrawal is one of the main risk factors for seizure activity. Seizure precautions are indicated. A nothing by mouth (NPO) order is indicated for a client experiencing substance withdrawal. Nausea and vomiting are common manifestations. Substance withdrawal can cause tachycardia and elevated blood pressure. Cardiac monitoring is indicated.
The nurse is providing teaching to client on the use of range of motion exercises while on bedrest. Which statement made by a client indicates the need for further teaching? A "I will move each joint through the full range at least 3 times." B "I should raise my leg with my foot 6 inches off the bed." C "I can move the joint until I feel resistance." D "I will hold my leg when someone rotates the joint."
D Rationale: Active range of motion exercises are movements that the client does independently. The client should be instructed to perform the active range of motion exercises. The nurse should instruct the client to perform the movement until resistance is felt. When exercising a joint, the movement should be done at least 3 times. When performing leg exercises, the client should lift the foot about 6 to 12 inches off the bed. Passive range of motion exercises are done with someone performing the exercise.
The home health nurse is conducting a safety visit with the family of a toddler who is crawling. Which statement by the parent would require follow-up by the nurse? A "We use a thermometer to test the temperature of the bath water." B "A gate was installed in the entryway to the kitchen." C "There are coverings placed over all electrical outlets." D "Any furniture with sharp edges we cover with a blanket."
D Rationale: Checking the water temperature reduces the risk of burns. Toddlers are unsteady and can fall easily on unsecured rugs. Toddlers put everything in their mouths so small objectives are a choking hazard. Covering the electrical outlets will prevent them from placing items in the outlet.
The nurse is planning care for a client who is receiving a hematopoietic stem cell transplant. Which actions should the nurse take? A Schedule open visiting hours with client's family B Monitor the client's vital signs once a shift C Provide the client with a pitcher of crushed ice D Keep client care equipment in the room
D Rationale: Clients who are receiving stem cell transplants are at high risk for infection. The nurse should plan interventions that prevent infection. The nurse should keep all client care equipment in the room and use dedicated equipment to prevent the spread of infection. The nurse will limit the visitors to the client to prevent exposure. The nurse should provide fresh water, replacing it every hour. The nurse should monitor the client's vital signs every four hours.
A nurse is performing an equipment check in a client's room. Which finding requires intervention? A The sequential compression device sleeves inflate and deflate. B The vital signs machine is connected to an outlet next to the window. C The portable monitor charging indicator light is on. D The excess infusion pump electrical cord is tied in a knot.
D Rationale: Electric cords should not be bent or twisted as this can cause the wires inside the cord to break. The nurse should loosen the cords. Outlets next to windows are not a safety hazard. The nurse should ensure electric cords are not near water sources. The charging light for heart monitors and defibrillators should be on, indicating that the batteries are charging. Sequential compression devices provide pressure to the leg in time increments. Inflation and deflation of the device is an expected finding.
The nurse is transporting a client in a motorized hospital bed when the cord becomes trapped under the wheel. The cord is visibly damaged. Which of the following actions is appropriate? A Have the client remain in the unplugged bed until it is repaired B Wrap the cord in electrical tape and continue to use the bed C Exchange the bed and leave it in the hallway for repair D Tag the bed for repair and remove it from the patient care area
D Rationale: Electrical equipment can present a safety hazard to both the patient and health care practitioner when safety measures are ignored. Electrical cords that are bent or twisted may have broken wires inside. Make certain that electric cords are not in a position to be trapped as beds are raised or lowered. This can strip insulation covering the electric wires. The bed should be removed from use and appropriately tagged for repair.
The nurse is providing education on prevention of repetitive stress injuries to an adult client who does virtual learning. Which of the following statements should be included in the teaching? A "Lean back against the office chair while sitting at the computer." B "Make the desktop higher than elbow height." C "Use a mousepad with a wrist rest." D "Float the wrists above the keyboard."
D* Rationale: Repetitive strain injury (RSI) is a general term used to describe the pain felt in muscles, nerves, and tendons caused by repetitive movement and overuse. The condition mostly affects the forearms and elbows, wrists and hands, and neck and shoulders. Leaning back against a desk chair can cause poor posture with hyperextension of the neck. Proper posture is essential to preventing RSI. The desktop should be at or below the level of the elbows to reduce shoulder strain. The wrists should be floating above all surfaces. A wrist rest can cause or worsen carpal tunnel syndrome.
