PP

The nurse is discharging a newborn with clubfoot who has had a cast applied. The nurse should provide additional teaching to the parents if they make which statement?

"I should use a pillow to elevate my child's foot as they sleep."

The nurse conducts a routine risk assessment at a prenatal visit. Which question would be bestto screen for intimate partner violence?

"How safe do you feel in your home?"

The nurse enters the room of a client who has an order for wrist restraints. The nurse notes that the wrist restraints are not properly applied. Where should the nurse fasten the restraint straps?

bed frame

The nurse is taking care of a client with neutropenia. Which nursing action is most important in preventing cross-contamination?

changing gloves immediately after use

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

check the medication orders.

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 is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is to:

ensure safety by initiating suicide precautions.

A nurse notices that a client admitted for treatment of major depression is pacing, agitated, and becoming verbally aggressive toward other clients. What is the immediate care priority?

ensuring the safety of this client and other clients on the unit

A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature?

every 15 minutes

Which action is the best precaution against transmission of infection?

eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection

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 nurse assesses an aggressive client. Which behavior warrants the nurse's prompt reporting and use of safety precautions?

naming another client as their adversary

A healthcare provider has entered orders for a client with chronic obstructive pulmonary disease (COPD). Which order should the nurse question?

oxygen increased to 3 L/minute if oxygen saturation is less than 94% on room air

An alert and oriented older adult client with metastatic lung cancer is admitted to the medical-surgical unit for treatment of heart failure. The client was given 80 mg of furosemide in the emergency department. The nurse is instructing the unlicensed assistive personnel (UAP) to implement a nursing plan to manage potential incontinence. Which instruction will be mosteffective for this client?

placing a commode at the bedside and instructing the client in its use

A client is scheduled for a renal arteriogram. No allergies are recorded in the client's medical record, and the client is unable to provide allergy information. During the arteriogram, the nurse should be alert for which assessment finding that may indicate an allergic reaction to the dye used?

pruritus

The nurse is caring for a client who is intubated. The health care provider has asked the nurse to mobilize the client in a way they feel may be unsafe. What should the nurse review to determine whether or not the practice is safe? Select all that apply.

the Nurse Practice Act standards from regulatory agencies guidelines published by a specialty professional organization the policies and procedures of the organization

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

Assess reflexes, clonus, visual disturbances, and headache.

The nurse has answered the telephone at the nurses' station, and the individual on the line states that there is bomb in the healthcare facility. What is the nurse's best response?

Keep the individual on the line in order to gather more information about the details of the threat.

The nurse manager of a surgical unit observes a nurse providing colostomy care to a client without using any personal protective equipment (PPE). What is the most appropriate response by the nurse manager in relation to PPE use?

"PPE should be used when you risk exposure to blood or bodily fluids."

A client with chronic progressive multiple sclerosis is learning to use a walker. What instruction will best ensure the client's safety?

"Place the walker directly in front of you and step into it as you move it forward."

The nurse teaches the parent of an infant who has had a surgical repair for a cleft lip about the use of elbow restraints at home. The nurse determines that the teaching has been successful when the parent makes which statement?

"We will only remove the restraints one at a time to check the skin under them for redness."

The parent of a school-age client with diabetes tells the nurse that they do not want the school to know about their child's condition. Which is the nurse's best response?

"What is it that concerns you about having the school know about your child's condition?"

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."

The nurse is caring for a client admitted for pneumonia with a history of hypertension and heart failure. The client has reported at least one fall in the last 3 months. The client may ambulate with assistance, has a saline lock in place, and has demonstrated appropriate use of the call light to request assistance. Using the Morse Fall Scale (see chart), what is this client's total score and risk level?

60, high risk

Which situations should a supervisor consider in making assignments for nurses in the neonatal unit?

A pregnant nurse shouldn't care for a neonate with cytomegalovirus (CMV).

A nurse is caring for a client with a fresh postoperative wound following a femoral-popliteal revascularization procedure. The nurse fails to routinely assess the pedal pulses on the affected leg, and missed the warning sign that the blood vessel was becoming occluded. The nurse manager is made aware of the complication and the nurse's failure to assess the client properly. What action should be taken by the nurse manager?

Address the nurse's omissions as negligent behavior.

A nurse is caring for a 10-month-old weighing 17.6 lb (8 kg) who was admitted for dehydration. The infant has an IV of 5% dextrose in 0.45% saline infusing at the maintenance rate of 100 mL/kg per day for children weighing 22 lb (10 kg) or less. The infant has vomited five times in the last 3 hours and has had no wet diapers in the last 8 hours. The nurse informs the health care provider. Which prescription should the nurse question?

Administer a 10 mL/kg fluid bolus of dextrose 25%.

A nurse is supervising a student during medication administration to a client. Which action by the student would cause the nurse to intervene during the med pass at the bedside?

Check the room number and the client's name on the bed.

A nurse assesses a client with psychotic symptoms and determines that the client likely poses a safety threat and needs vest restraints. The client is adamantly opposed to this. What would be the best nursing action?

Contact the physician and obtain necessary orders.

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.

A nurse observes a second nurse documenting a peripheral blood glucose level that the second nurse did not actually collect from a client with diabetes. What is the priority action by the nurse observing this situation?

Discuss the observation with the other nurse.

The nurse is assisting a healthcare provider in debriding a necrotic skin wound. The healthcare provider is using a plastic basin to collect the bloody supplies. When cleaning the area on completion of debridement, which nursing action is done after placing the supplies in a hazardous material bag?

Dispose of the plastic basin.

When assisting a community after a hurricane, the nurse determines that the community members are in the disillusionment phase of disaster recovery. What is the most appropriate intervention by the nurse when working with individual members?

Encourage them to verbalize their feelings.

Which nursing action best addresses the outcome: The client will be free from falls?

Encourage use of grab bars and railings in the bathroom and halls.

A client is upset the nurse has put a belt restraint on them. Which action should the nurse take when teaching the client and their family members about the use of this restraint?

Explain that its purpose is to help prevent injury to the client.

The nurse is admitting a client with glaucoma. The client brings prescribed eye drops from home and insists on using them in the hospital. What should the nurse do?

Explain to the client that the health care provider (HCP) will write a prescription for the eye drops to be used at the hospital.

A nurse asks their nurse colleague to help bathe their client. The nurse colleague notices that the nurse has applied restraints in an unsafe manner. What should the nurse colleague do first?

Express concern about the practice to the nurse.

A client is to have a below-the-knee amputation. Before the surgery, what should the circulating nurse in the operating room do?

Initiate a time-out.

A hospitalized client, with a productive cough, chills, and night sweats is suspected of having active tuberculosis (TB). What is the nurse's most important intervention?

Maintain the client on respiratory isolation

What is the priority action that a nurse should take after omitting an ordered medication?

Notify the prescriber.

While changing bed linens the nurse notices a metal object on the bottom sheet of a client with radiation seeds implanted in the bladder. Which action should the nurse take? Select all that apply.

Notify the radiation department. Walk away from the item.

The nurse is planning care for a client who has an allergy to latex. What intervention would be the priority for the nurse to include in the plan of care?

Place latex-free, powder-free gloves at client's bedside.

A client is having a nosebleed. What should the nurse do next?

Place the client in a sitting position with the neck bent forward and apply firm pressure on the nasal septum.

A nurse has drawn up more than the prescribed amount of morphine for a client who is reporting pain. Because the nurse was in a hurry, they disposed of the extra medication before an authorized staff member arrived. Which is the best response from the staff member after the nurse asks for their signature to verify they wasted part of the dose?

Refuse to verify that they witnessed the disposal of the extra medicine.

A nurse is concerned for the safety of their clients after noting a staff member is not properly prepping the intravenous bags before attaching them to the client. Which action(s) should the nurse perform when handling this situation? Select all that apply.

Remain calm and positive with the individual making the error. Report the unsafe practice to the appropriate person. Document the situation with factual information.

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

Remove any unsafe items from the area in which the infant is mobile.

A nurse enters a client's room and finds a pillowcase on fire where it was placed over a table lamp. Which action should the nurse perform first?

Remove the client from the room.

When the nurse is removing personal protective covering, what action should this nurse (see figure) take to avoid spreading nosocomial infections?

Remove the face mask.

While reviewing the day's charts, a nurse who's been under a great deal of personal stress realizes that the nurse forgot to administer insulin to client with diabetes mellitus. The nurse has made numerous errors in the past few weeks and is now afraid this job is in jeopardy. What is the best course of action?

Report the error, complete the proper paperwork, and meet with the unit manager.

A nurse suspects that a coworker is taking and using narcotics from the medication cart. What would the nurse do first?

Report the suspicion to the nurse manager.

A nurse prepares to transfer a client from a bed to a chair. Which principle demonstrates safe body mechanics?

The nurse uses a rocking motion while helping the client to stand.

The nurse is caring for a neonate diagnosed with early-onset sepsis and is being treated with intravenous antibiotics. Which instructions will the nurse include in the parents' teaching plan?

Wash hands thoroughly before touching the neonate.

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.

Which client has a greater risk for latex allergies?

a woman who is admitted for her seventh surgery

A client is exhibiting violent behavior, and the health care provider has ordered leather restraints to be placed on the client's arms and legs. A team responds to the room to assist with holding the client while the restraints are applied. Where should the nurse instruct the team to hold the client while placing the restraints?

above and below the joints in the arms and legs

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 nurse is admitting a client with suspected tuberculosis to the hospital. The nurse should institute which type of precautions for this client?

airborne precautions

The charge nurse is assessing assignments for staffing on a medical-surgical floor. Which client(s) will the nurse place in droplet precautions? Select all that apply.

an older adult client with influenza a client with bacterial meningitis

The client has various sensory impairments associated with type 1 diabetes. The nurse determines that the client needs further instruction when the client makes which statement? I will:

avoid kitchen activities.