Safety and Infection Control

A farm worker comes into the clinic reporting headache, dizziness, and muscle twitching after working in the fields. What condition does the nurse suspect? 1. Pesticide exposure 2. Heat stroke 3. Anthrax poisoning 4. Gastroenteritis

Pesticide exposure

An 18 month old is admitted to the unit with a diagnosis of pertussis. The mother asks the nurse, "How did my child get this disease? I didn't think anyone got that anymore." What is the best response by the nurse? 1. "Pertussis is a common childhood disease since there is no vaccine." 2. "Since not all children are immunized against pertussis, the disease has reemerged." 3. "Your baby got this disease because you didn't have your child immunized." 4. "Since your child is already sick, let's just focus on getting well."

"Since not all children are immunized against pertussis, the disease has reemerged."

A suicidal client confides to the night nurse, "I will try again when I get out of this place." What is the nurse's best response? 1. "What do you plan to do?" 2. "You will try again?" 3. "Why would you want to do that? You have everything to live for." 4. "Are you trying to punish your family for sending you here?"

1. "What do you plan to do?"

A nurse enters the operating room (OR) with artificial nails in place. What should the charge nurse explain to the nurse? Select all that apply: 1. Pathogenic bacteria can be found on the fingertips of those who wear artificial fingernails. 2. Artificial nails are allowed to be worn in the OR. 3. Fungal growth can occur under the artificial nail, thus increasing the risk of surgical site infection to the client. 4. A more vigorous scrub is required if artificial nails are worn. 5. Long nails and artificial nails increase microbial load on the hands.

1. Pathogenic bacteria can be found on the fingertips of those who wear artificial fingernails. 3. Fungal growth can occur under the artificial nail, thus increasing the risk of surgical site infection to the client. 5. Long nails and artificial nails increase microbial load on the hands.

Which prescriptions would the nurse recognize as being appropriate for the client with shingles? Select all that apply: 1. Private room 2. Negative-pressure airflow 3. Respirator mask 4. Face Shield 5. Positive pressure room

1. Private room 2. Negative-pressure airflow 3. Respirator mask

A client is admitted to the pediatric unit with a diagnosis to rule out tuberculosis (TB). What room assignment by the charge nurse would be best? 1. Private room only. 2. Private room and place on protective isolation. 3. Room with a client with a respiratory infection. 4. Room with a client who is 24 hours post operative.

1. Private room only.

The nurse is working with a group of teenage girls who are at risk for acquiring a sexually transmitted disease (STD). What should the nurse teach these clients to prevent them from acquiring or transmitting Chlamydia? Select all that apply: 1. Using a latex condom when having sex will protect against STDs. 2. Seek the advice of a primary healthcare provider if there is a vaginal discharge or burning on urination. 3. Suggest that the teens be screened for Chlamydia. 4. Reassure the teens that if they have no symptoms, they have no disease. 5. Take prescribed medication if diagnosed with Chlamydia, and repeat screening in three months.

1. Using a latex condom when having sex will protect against STDs. 2. Seek the advice of a primary healthcare provider if there is a vaginal discharge or burning on urination. 3. Suggest that the teens be screened for Chlamydia. 5. Take prescribed medication if diagnosed with Chlamydia, and repeat screening in three months.

The client in the manic phase of bipolar disorder begins climbing onto a table in the day room and shouts, "I can fly! I can fly! Watch me fly!" What should be the priority intervention by the nurse? 1. Leave the client alone since this is a form of exercise. 2. Call for personnel to escort the client out of the day room. 3. Restrain the client, and notify the primary healthcare provider. 4. Calmly explain to the client that there is no way that a person can fly.

2. Call for personnel to escort the client out of the day room.

A home health nurse is evaluating the home of new parents of an adoptive two year old child. Which observations should the nurse discuss with the parents as potential safety threats? Select all that apply: 1. Security gates at the stairs. 2. Cleaning supplies under sink cabinet. 3. No blinds on windows. 4. Use of space heaters. 5. Water heater temperature 140°F (60°C)

2. Cleaning supplies under sink cabinet. 4. Use of space heaters. 5. Water heater temperature 140°F (60°C)

The nurse is caring for a client in the emergency department (ED). What will the nurse plan to use to ensure proper identification of the ambulatory and alert client? Select all that apply: 1. Room number 2. Date of birth 3. Identification band 4. Correctly stating his/her name 5. Telephone number

2. Date of birth 3. Identification band 4. Correctly stating his/her name

A nurse is working with community officials to decrease the incidence of violence in the community. Which preventive measures might the nurse suggest? Select all that apply: 1. Provide a safe haven for victims of violence. 2. Provide educational programs about types of violence. 3. Form a neighborhood watch program. 4. Develop a media campaign identifying risk factors of potential abuse. 5. Provide for the immediate removal of a victim of violence from the home.

2., 3. & 4. Correct: These are all appropriate interventions for the nurse to suggest to the community. The key is prevention.

A home health nurse is planning home safety education for a client and spouse. Which plan would be best to ensure fire safety in the home setting? Select all that apply: 1. Smoking in bed is acceptable if you are not sleepy. 2. Keep matches and lighters away from children by storing them in a locked cabinet. 3. Install carbon monoxide smoke alarms and test monthly. 4. You may leave Christmas lights lit all night as long as the tree is artificial. 5. Have a planned route of exit and place where all family member will meet.

2., 3. & 5. Correct: Keeping matches and lighters away from children by storing them in a locked cabinet can prevent fire-related deaths. Carbon monoxide smoke alarms will alarm for smoke and carbon monoxide which is an odorless gas than can kill quickly. Alarms should be tested every month and repaired or replaced immediately if malfunction occurs. A plan facilitates exit from the building and place to meet helps identify that all family is out of the building.

The nurse is caring for a client while fluorouracil is being infused. The client complains of burning at the intravenous (IV) site. What should the nurse do first? 1. Apply warm compresses. 2. Slow the infusion. 3. Inspect the IV site. 4. Stop the infusion.

4. Stop the infusion.

A nurse is preparing a lecture about suicide. Which target audience would be most appropriate? 1. A group of high school teachers 2. A group of girl scout leaders 3. A support group for divorced parents 4. A group of hispanic immigrant farm workers

1. Correct: Among those who commit suicide, young men between the ages of 15-24 are more likely to commit suicide than young girls and women. The best line of defense is to teach about the warning signs of suicide to teachers, students, and parents of teens and young adults, particularly male.

The unit charge nurse is responsible for reporting all healthcare associated infections. Which client condition needs to be reported? 1. A client diagnosed with Clostridium Difficile while receiving intravenous (IV) antibiotics. 2. A client admitted with Methicillin-resistant Staphylococcus aureus (MRSA) in a wound. 3. A client with ulcerative colitis exhibiting diarrhea. 4. A client with a fever of 99.2ºF (37.3°C) two days post gastrectomy.

1. Correct: Clostridium Difficile is a spore forming bacterium that has significant healthcare-associated infections (HAI) potential.

The nurse is reviewing the medication prescriptions with a Spanish speaking client for an antibiotic to be taken once per day. Which nursing intervention is most likely to prevent a medication error with clients who do not speak the dominant language? 1. Use the teach-back method so that clients are repeating the instructions back to the nurse. 2. Give printed information to the client. 3. Ask the client if he/she has questions before the client leaves the healthcare setting. 4. Refer medication questions to the pharmacist.

1. Correct: The teach-back method of asking the client to repeat the teaching instructions to the nurse will most likely forewarn of any misunderstanding.

The nurse is planning to teach a group of assisted living residents about preventing the spread of tuberculosis (TB) infection. What should the nurse include? Select all that apply: 1. Cover mouth when coughing. 2. Proper handwashing. 3. Obtain a TB skin test. 4. Yearly chest x-ray. 5. Proper disposal of tissues

1. Cover mouth when coughing. 2. Proper handwashing. 3. Obtain a TB skin test. 5. Proper disposal of tissues

The home health nurse is caring for a client that is identified as high risk for falls. What evaluation would indicate a therapeutic response to home fall prevention education? Select all that apply: 1. Installs a grab bar in the tub. 2. Turns night lights on at bedtime. 3. Uses assistive devices only when leaving home. 4. Goes barefoot while in the home. 5. Uses throw rugs in walking areas to prevent slipping.

1. Installs a grab bar in the tub. 2. Turns night lights on at bedtime.

The nurse is making a home assessment for the purpose of preventing injury for a visually impaired elderly client who also has diabetes. Which observations are important for the nurse to include in this assessment? Select all that apply: 1. Have there been bouts of anxiety? 2. Are there scatter rugs on the floor? 3. Does the client have adequate lighting? 4. Are the eye glasses functional? 5. Is the client wearing well-fitting closed toe shoes?

2. Are there scatter rugs on the floor? 3. Does the client have adequate lighting? 4. Are the eye glasses functional? 5. Is the client wearing well-fitting closed toe shoes?

The nurse is working in the operating room. Which actions should be performed to prevent injury from a needle stick? Select all that apply: 1. Recap the needle after use to prevent injury. 2. Clean used instrument trays carefully after every procedure. 3. After drawing up saline to flush an intravenous (IV), place the syringe in a pocket to prevent possible injury. 4. Replace the puncture resistant biohazard container when three-quarters full. 5. Use "needleless" devices whenever possible.

2. Clean used instrument trays carefully after every procedure. 4. Replace the puncture resistant biohazard container when three-quarters full. 5. Use "needleless" devices whenever possible.

The nurse is caring for a client diagnosed with major depression post electroconvulsive therapy (ECT). What nursing interventions should be included in this post treatment period? Select all that apply: 1. Monitor vital signs every hour for eight hours. 2. Position the client on their side. 3. Stay with the client until fully awake. 4. Provide flexibility in scheduling routine activities. 5. Encourage the client to ambulate in room and hall.

2. Position the client on their side. 3. Stay with the client until fully awake.

A client recently diagnosed with diabetes is sent home with a prescription for subcutaneous insulin. What statement made by the client indicates that teaching has been effective regarding safe needle disposal? 1. "I should wrap the needle in a paper towel and place in the trash." 2. "I should use a hospital issued biohazard container for all needles." 3. "I may use any hard plastic container with a screw-on cap." 4. "I should bring my needles to the nearest hospital for disposal. "

3. "I may use any hard plastic container with a screw-on cap."

The nurse working in a pediatrician's office is teaching an adult couple with small children about proper medication administration for children. What statement by the couple would indicate that further teaching is needed? 1. We should carefully measure elixir medication with the provided dropper. 2. Our children should not watch us take medicine. 3. We tell our children the medicine is candy so they will take it without a fuss. 4. Even though medicine comes in a childproof container, we will put medication out of reach.

3. Correct: Calling medication "candy" is inappropriate and misleading to the child. Children may take medication to eat as candy if they have access to it..

A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg intramuscularly (IM). The newborn weighs 6 pounds (2.7 kg). The dispensed dose is 25,000 units per 1 mL. What should the nurse do? 1. Administer the drug intravenously (IV) since a large volume is required. 2. Choose three injection sites and give the medication as prescribed. 3. Consult with the pharmacy for a different medication concentration. 4. Read the available drug information to determine how to administer the medication.

3. Correct: The nurse must consult with the pharmacy to receive further instructions. The dose is greater than the allowed volume to be given IM, which warrants clarification by the pharmacy.

A school nurse is caring for a child that fell on the playground. Upon examination of the child, the nurse notes multiple bruises in various stages of healing. What is the nurse's priority intervention? 1. Ask the parents who hit the child on the back. 2. Notify the child's primary healthcare provider. 3. Contact the Department of Health and Human Services. 4. Document the findings and observe the child over the next week.

3. Correct: Unless there is a policy to direct otherwise, the nurse who suspects child abuse is obligated to report it to the Department of Health and Human Services.

The circulating nurse prepares the sterile field in the operating room (OR). Fifteen minutes later, the nurse is informed the surgery will be delayed for 20 minutes because the surgeon is working at another hospital. Which is the best action for the nurse to take? 1. Cover the sterile field with a sterile drape until the surgery is about to begin. 2. Close and tape the OR doors so that no one may enter. 3. Monitor the sterile field while awaiting the surgeon. 4. Tear down the sterile field until the surgeon arrives in the OR.

3. Monitor the sterile field while awaiting the surgeon.

The nurse is caring for a client undergoing electroconvulsive therapy (ECT) for major depression. What is the nurse's most important intervention during the treatment? 1. Monitor vital signs and cardiac functioning. 2. Provide support to the client's arms and legs. 3. Provide suctioning as needed. 4. Place electrodes on temples.

3. Provide suctioning as needed.

A client is admitted with irritable bowel syndrome (IBS) and shingles. The charge nurse is making assignments. Which staff member should not be assigned to this client? 1. A nurse with history of roseola. 2. A unlincesed assitive personnel (UAP) with no history of roseola. 3. A UAP with history of chicken pox. 4. A LPN/VN with no history of chicken pox.

A LPN/VN with no history of chicken pox.

A client comes into the emergency department (ED) and demands to be seen immediately, but refuses to tell the triage nurse the problem. During the initial assessment, the client starts yelling and shaking their fist. What should be the nurse's initial action? 1. Tell the client to stay calm, and they will be treated soon. 2. Explain that unless the client behaves, they will be sent away from the ED. 3. Notify the client that security will be called if they do not go to the waiting room immediately. 4. Find a safe place away from the client and then notify security.

Find a safe place away from the client and then notify security.

What information should be included when a nurse is teaching a group of college students about the transmission of hepatitis B and human immunodeficiency virus (HIV)? 1. HIV is transmitted via toilet seats whereas hepatitis B is not. 2. HIV is transmitted by sexual contact whereas hepatitis B is not. 3. Hepatitis B is more readily transmitted via needle sticks than HIV. 4. Neither virus is transmitted via body fluids.

Hepatitis B is more readily transmitted via needle sticks than HIV.

When preparing to administer the client a dose of intravenous (IV) antibiotics, the nurse notes the IV pump cord is frayed with wiring visible. What priority action should the nurse take? 1. Notify maintenance to come and check the pump immediately. 2. Continue with the administration of antibiotic and fill out an equipment maintenance request. 3. Obtain a replacement pump. 4. Tag the equipment for maintenance.

Obtain a replacement pump.

The nurse is performing morning care on a client on the medical unit. What should the nurse do after changing a client's bed linen? 1. Hold the linen close to the body while transporting it to the dirty utility room. 2. Wear a gown and gloves to transport the linen to the biohazard container. 3. Placed the linen into a leak proof container sitting outside the room. 4. Place the linen in a pillow case and set it on the floor until client care is completed.

Placed the linen into a leak proof container sitting outside the room.

The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). Which action should the nurse stop the UAP from performing? 1. Emptying the Jackson-Pratt (JP) drainage of the client post cholecystectomy. 2. Performing passive range of motion (ROM) on the client with right sided paralysis. 3. Placing the traction weights on the bed to transfer the client to x-ray. 4. Discarding the first urine voided by the client starting a 24 hour urine test.

Placing the traction weights on the bed to transfer the client to x-ray.

The nurse is assisting in decontaminating a client who was recently involved in a chemical exposure event. What should the nurse do first? 1. Rinse the client off with a copious amount of water. 2. Remove clothing from the client. 3. Wash the client with a saline solution. 4. Flush the skin with an antibacterial agent.

Remove clothing from the client.

A client is brought into the emergency department (ED) with nausea, vomiting and diarrhea after eating chicken at a picnic. The nurse suspects that this client has contracted which infection? 1. Shigella Infection 2. Escherichia coli Infection 3. Clostridium Difficile Infection 4. Salmonella Infection

Salmonella Infection

The charge nurse observes a staff nurse caring for a new mother with oral herpes simplex type I. Which behavior by the nurse indicates that further instruction on transmission of this disease is needed? 1. Instructs the new mother that she should not kiss the newborn. 2. Wears gloves during the perineal and lochia assessment. 3. Washes her hands before and after each client contact. 4. States that the newborn may contract herpes from the birth canal.

States that the newborn may contract herpes from the birth canal.

What should the nurse include in the plan of care for a child with newly diagnosed leukemia, who is receiving chemotherapy? 1. Place the child in a negative pressure isolation room. 2. Administer prophylactic intravenous (IV) antibiotics. 3. Avoid high protein food intake. 4. Teach family and visitors handwashing techniques.

Teach family and visitors handwashing techniques.

A client has been diagnosed with genital herpes. Which comment indicates understanding of the disease and prevention of the spread of the disease? 1. "I can be treated and then no one else is at risk." 2. "Using condoms will keep my sex partner from acquiring the disease." 3. "If I have no sores, I am not contagious to anyone." 4. "My sex partner should be tested because we have not always used condoms."

"My sex partner should be tested because we have not always used condoms."

A nurse works in the operating room (OR) as a circulator. Which actions should the nurse perform to help prevent surgical-site infections? Select all that apply: 1. Close the OR doors at all times during a surgical case. 2. Minimize traffic in the OR. 3. Ensure the room has negative flow. 4. Monitor the sterile field at all times. 5. Immediately discard any object that becomes contaminated.

1. Close the OR doors at all times during a surgical case. 2. Minimize traffic in the OR. 4. Monitor the sterile field at all times. 5. Immediately discard any object that becomes contaminated.

The nurse is caring for a client with a perineal burn. The skin is not intact. What signs are suggestive of infection? Select all that apply: 1. Color Changes 2. Drainage 3. Odor 4. Fever 5. Bleeding 6. Increased Pain

1. Color Changes 2. Drainage 3. Odor 4. Fever 6. Increased Pain

While teaching about infection prevention because of a low white count to a client and their family, what points should the home health nurse include? 1. Avoid people who are ill. 2. Eat raw vegetables. 3. Clean all surfaces with bleach daily. 4. Wash clothes separately from the rest of the family with disinfectant.

1. Correct: People with a low white count cannot fight off infection. They do not need to be exposed to people who are ill.

Which discussion points should a nurse plan to include when teaching a group of college students on prevention of sexually transmitted diseases (STD)? Select all that apply: 1. Safe sex practices 2. Routine human immunodeficiency virus (HIV) testing 3. Proper use of a condom 4. Sexual abstinence 5. Religious views related to abstinence

1. Safe sex practices 3. Proper use of a condom 4. Sexual abstinence

A nurse is teaching a group of small farm owners how to prevent pesticide exposure for field workers. What points should the nurse include? Select all that apply: 1. Importance of hand washing before eating. 2. Wearing protective clothing while working in the field and at home. 3. Removing clothing and shoes worn in the field before entering the home. 4. Washing fruit and vegetables prior to eating. 5. Boiling all vegetables for a minimum of 5 minutes prior to eating.

1. Importance of hand washing before eating. 3. Removing clothing and shoes worn in the field before entering the home. 4. Washing fruit and vegetables prior to eating.

Prior to taking necessary supplies into a surgical suite where the surgery case may involve blood, what personal protective equipment (PPE) should the nurse plan to wear? Select all that apply: 1. Mask 2. Hair covering 3. Surgical scrubs 4. Shoe covers 5. Gown

1. Mask 2. Hair covering 3. Surgical scrubs 4. Shoe covers 5. Gown

Following a thyroidectomy, a client reports shortness of breath and neck pressure. Which nursing action is the best response? 1. Stay with the client, remove the dressing, and elevate the head of bed. 2. Call a code, open the trach set and position the client supine. 3. Obtain vital signs. 4. Immediately go to the nurse's station and call the primary healthcare provider.

1. Stay with the client, remove the dressing, and elevate the head of bed.

The nurse is preparing a client for transport to the radiology department for a left lung tissue biopsy. Which activities should the nurse make certain have been completed? Select all that apply: 1. The consent form is signed. 2. The operative site is prepped with a razor. 3. The most recent lab work is on the chart. 4. Any preoperative medication is given as prescribed. 5. Person performing the procedure marks the site.

1. The consent form is signed. 3. The most recent lab work is on the chart. 4. Any preoperative medication is given as prescribed. 5. Person performing the procedure marks the site.

The nurse is working to orient a new graduate nurse on the surgical unit. Which actions by the new nurse, requires intervention? 1. The two-handed method is used to recap a needle. 2. A needleless system is used to give medication through an intravenous (IV). 3. A blunt cannula is used to withdraw medication from a vial. 4. An engineered sharp injury protective device is used to recap a used needle.

1. The two-handed method is used to recap a needle.

Prior to taking necessary supplies into a surgical suite where the surgery case may involve blood, what personal protective equipment (PPE) should the nurse plan to wear? Select all that apply: 1. Mask 2. Hair covering 3. Lab coat 4. Shoe covers 5. Gown 6. Surgical scrubs

1., 2., 4., 5., & 6.Correct: Hair covering is donned first to prevent hair from falling on fresh surgical scrubs. A mask is worn to prevent dispelling droplets into the sterile field. Shoe covers are worn when there are cases that may involve blood. Gowns are worn to protect the nurse from splashes or spills. Surgical scrubs are worn to prevent shedding.

A new mother asks the clinic nurse why her baby should receive recommended vaccinations. What is the best response by the nurse concerning vaccinations? 1. "They give antibodies to your baby to protect them from disease." 2. "They will help your baby to produce antibodies against disease causing organisms." 3. "They are required by law." 4. "They may cause a mild, uncomfortable reaction."

2. "They will help your baby to produce antibodies against disease causing organisms."

The nurse is preparing to discharge a client home from the hospital. Which statement, made by a client indicates to the nurse that instructions about antibiotic administration have been successful? Select all that apply: 1. "Take most of the antibiotic until I feel better, but save some to take in case the infection returns." 2. "Follow the instructions on the label." 3. "Double the dose for two days so I will get better sooner." 4. "Double the dose the next time the antibiotic is due after missing a dose." 5. "Finish all of my antibiotic medication."

2. "Follow the instructions on the label." 5. "Finish all of my antibiotic medication."

The nurse manager is performing a chart audit for clients who were restrained. For which client would the side rails in the up position be considered a restraint? 1. The client who requests that the rails be placed in the up position. 2. The client who is confused and wanders about the unit. 3. The client who is ambulatory and places the side rails up without staff assistance. 4. The client who asks the family to place all the rails up before leaving.

2. The client who is confused and wanders about the unit.

A nurse notes redness, warmth, and pain at a client's intravenous (IV) insertion site. What does the nurse expect? 1. Colonization 2. Infection 3. Infectious disease 4. Bacteremia

2. Correct: Infection indicates host interaction with an organism. Clinical evidence includes redness, heat and pain.

A nurse drops a bottle of intralipid fluid, which shatters on the floor in the hallway. What action should the nurse take? 1. Notify housekeeping to clean up the spill. 2. Pick up glass with a broom and dustpan and dispose into a puncture resistant sharps container. 3. Pick up the glass with gloved hands and dispose into a puncture resistant sharps container. 4. Use a wet mop to collect the glass and dispose of it in the garbage can.

2. Correct: Proper removal of glass includes using a dustpan and broom to collect the glass and disposing of it into a puncture resistant sharps container.

A nurse has responded to the scene of a natural disaster to triage clients. Which client should the nurse triage with a black disaster tag? 1. One with a traumatic amputation to the left lower leg. 2. One with 2nd and 3rd degree burns over 75 % of the body. 3. One suffering with a fracture of the humerus. 4. One with a blood pressure of 90/40 and lethargic.

2. One with 2nd and 3rd degree burns over 75 % of the body.

The nurse is preparing a client for surgery. Which methods are appropriate for the nurse to use in removing excessive body hair? 1. Shaving the hair with a razor. 2. Removing the hair with clippers. 3. Lathering the skin with soap and water prior to shaving with a razor. 4. Using a depilatory cream. 5. Always use a new, sharp razor.

2. Removing the hair with clippers. 4. Using a depilatory cream.

The nurse is teaching a group of high school students about car accident prevention. What should the nurse include as the highest risk for a motor vehicle crash (MVC)? 1. Males who have just turned 19 years of age. 2. Drivers who have recently acquired a driver's license. 3. A group of students that car-pool to the senior prom. 4. Female students who drive to weekly football games.

2. Drivers who have recently acquired a driver's license.

In the event of a medication incident, which situations should the nurse notify the primary healthcare provider? Select all that apply: 1. All of the time. 2. Client is harmed or dies. 3. Medication incident is a near miss. 4. Nurse administers an incorrect dosage. 5. Client questions the medication color.

2.& 4. Correct: The primary healthcare provider should be notified if harm is brought to the client or death occurs as a result of the medication incident. The primary healthcare provider should be notified if the nurse administers an incorrect dosage to the client. An incident report needs to be completed in this situation.

The nurse is working in a long term care facility. What actions by the nurse are appropriate when taking a telephone prescription from a primary healthcare provider? Select all that apply: 1. Document the prescription prior to the end of the shift. 2. Explain to the pimary healthcare provider that nurses cannot take telephone prescriptions. 3. Repeat the prescription back to the primary healthcare provider prior to hanging up. 4. Transcribe the prescription in the client's record. 5. Ask the primary healthcare provider to wait and write the prescription during rounds.

3. Repeat the prescription back to the primary healthcare provider prior to hanging up. 4. Transcribe the prescription in the client's record.

A new mother calls the clinic and tells the nurse, "I don't have any help taking care of my baby. I don't know what to do. I just feel like I can't take care of him anymore. I wish I never had him sometimes. Maybe then my husband would spend more time at home." What would be the nurse's best response? 1. "You are experiencing maternity blues which will go away on its own." 2. "You are just tired. Tell your husband that you need his help." 3. "Come to the clinic now so that we can help you." 4. "Have you thought about getting a family member to help with the baby?"

3. "Come to the clinic now so that we can help you."

The nurse working in a pediatrician's office teaches an adult client with four children about utilizing a booster seat in a vehicle. For which age child is a booster seat appropriate? 1. 1 year of age, 21 pounds (9.5 kg) 2. 3 years of age, 34 pounds (15.5 kg) 3. 5 years of age, 45 pounds (20.5 kg) 4. 9 years of age, 63 pounds (28.6 kg)

3. 5 years of age, 45 pounds (20.5 kg)

The triage nurse in the emergency department (ED) assesses 4 clients. Which client is in need of emergent care? 1. A 52 year old who has a partially amputated finger. 2. A 9 month old with temperature of 103°F (39.4°C). 3. A two year old with excessive drooling and a weak cough. 4. A 28 year old experiencing a migraine headache for three days.

3. A two year old with excessive drooling and a weak cough.

A nurse is evaluating an unlicensed assistive personnel (UAP) for proper body mechanics while lifting a heavy object off of the floor. What action by the UAP would indicate a need for further instruction by the nurse? 1. Testing the weight to determine if additional assistance is needed. 2. Keeping the feet shoulder width apart. 3. Bending from the waist to pick up the object. 4. Holding the object close to the body upon rising.

3. Bending from the waist to pick up the object.

The parent of an infant asks the nurse when the child is old enough to ride without a special car restraint or safety seat. Which statements by the nurse are correct? Select all that apply: 1. Your infant can ride without a special car restraint when they weigh 15 pounds (6.8 kg). 2. Children can ride in the front seat when they weigh at least 10 pounds (4.5 kg). 3. Children should use special car restraints until 57inches in height or 8-12 years old. 4. Booster seats may be used for the infant when they are able to hold their head up for long periods. 5. Parents should obtain the most up to date information from their pediatrician about car restraints.

3. Children should use special car restraints until 57inches in height or 8-12 years old. 5. Parents should obtain the most up to date information from their pediatrician about car restraints.

The primary healthcare provider instructs the nurse to place body tissue obtained from a biopsy into a container with formalin prior to sending it to pathology. The nurse has not handled formalin before. What would be the nurse's best action? 1. Call the pathology department for directions on formalin's use and precautions. 2. Look formalin up in the drug handbook 3. Read about formalin on the Material Safety Data Sheet (MSDS). 4. Explain to the primary healthcare provider that nurses are not allowed to use formalin.

3. Read about formalin on the Material Safety Data Sheet (MSDS).

A nurse is caring for a nonambulatory client who must be decontaminated after a chemical exposure event. What nursing action will best prevent further chemical exposure? 1. Don appropriate personal protective equipment (PPE). 2. Remove only contaminated clothes. 3. Avoid decontaminating the eyes. 4. Use hot water during decontamination.

Don appropriate personal protective equipment (PPE).

The nurse is caring for a client with an infected wound. The nurse performs hand hygiene and puts on gloves prior to changing the dressing on the wound. After changing the dressing, the nurse discards the dressing and proceeds to change the bed, straighten the bedside table, and pour the client a glass of water. How did the nurse contaminate the client's environment? 1. The nurse did not perform hand hygiene after changing the dressing. 2. The nurse did not use an alcohol scrub before changing the dressing. 3. The nurse did not wash the client's hands after the dressing change. 4. The nurse touched other items and articles in the client area with soiled gloves.

4. The nurse touched other items and articles in the client area with soiled gloves.

While preparing a fact sheet for a client diagnosed with a vancomycin-resistant enterococcus (VRE) urinary tract infection (UTI), the home health nurse should include which instructions? Select all that apply: 1. Wash hands with hot water and soap when hands are soiled. 2. Clean the bathroom and kitchen with soap and water. 3. Gloves are not needed in the home since contamination with VRE has already occurred. 4. Wash hands after using the bathroom and before preparing food. 5.Clean the bathroom and kitchen with warm water and bleach.

4. Wash hands after using the bathroom and before preparing food. 5.Clean the bathroom and kitchen with warm water and bleach.

An elderly client is seen in the clinic expressing feelings of hopelessness and despair after losing his wife two months ago. He tells the nurse, "I think I am ready to go meet her. Please don't tell anyone." How should the nurse respond? 1. "I can see that you miss your wife very much." 2. "Tell me about your medications." 3. "I will keep your secret if you promise me you won't do anything until we talk again." 4. "I can't keep a secret like that. Are you planning to harm yourself?"

4. Correct: This client is contemplating suicide. The nurse has a responsibility to get the client help.

After a heart catheterization a client reports severe foot pain on the side of the femoral stick. The nurse notes pulselessness, pallor, and a cold extremity. What should be the nurse's first action? 1. Administer an anticoagulant. 2. Warm the room. 3. Increase intravenous (IV) fluids. 4. Notify the primary healthcare provider stat.

4. Notify the primary healthcare provider stat.

The following clients arrive to the emergency department (ED) at the same time. The triage nurse gives priority to which client? 1 . A client with a possible fracture of the tibia 45 minutes ago. 2. A client with left hemiparesis and aphasia beginning 1 hour ago. 3. A client smelling of alcohol and complaining of severe abdominal pain. 4. A client involved in a motor vehicle accident (MVA) with a possible fractured pelvis.

A client with left hemiparesis and aphasia beginning 1 hour ago.

Which action by a nurse would indicate that this nurse is following standard precautions? 1. Clean gloves while performing a heel stick on an infant. 2. Sterile gloves to empty a indwelling urinary catheter bag. 3. Shoe covers when entering the room of a client with influenza. 4. Clean gloves while inserting a urinary catheter.

Clean gloves while performing a heel stick on an infant.

Which information should the nurse plan to teach to family members of a client diagnosed with hepatitis B to decrease their risk of exposure? 1. Do not share personal items with the client, such as razors or toothbrushes. 2. Wash dishes separately from the rest of the family's. 3. Wear a surgical mask when in close proximity to the client. 4. Use a separate bathroom from the client.

Do not share personal items with the client, such as razors or toothbrushes.

The nurse administers chemotherapeutic drugs to a client with breast cancer. Where should the nurse dispose of the medication vials? 1. In a puncture-resistant biohazard container 2. In a chemotherapy sharps container 3. In a biohazard waste container 4. In a chemical container

In a chemotherapy sharps container

The charge nurse is observing a new nurse perform a dressing change on a client with a Stage III pressure ulcer. What observation by the charge nurse would indicate a need for further teaching? 1. Irrigates the pressure ulcer with 50ml normal saline. 2. Irrigates the pressure ulcer with half-strength hydrogen peroxide. 3. Packs the wound with sterile Kerlix soaked in normal saline. 4. Applies a Duoderm dressing over the wound after cleansing.

Irrigates the pressure ulcer with half-strength hydrogen peroxide.

During shift change the night charge nurse reported to the day charge nurse that the client admitted with an ingestion of unknown drugs, was physically restrained last night at 2000 pm. The client was incoherent, combative, and attempting to leave the facility. No family members were present. The night charge nurse noted that there was no primary healthcare provider order for the restraints. On last assessment 30 minutes ago, the client was still combative. What is the best action by the day shift charge nurse? 1. Since the client is still combative, continue the restraints. 2. Remove restraints until the primary healthcare provider hand writes the order. 3. Assign a unlicensed assistive personnel (UAP) to check on the client periodically. 4. Obtain an order from the primary healthcare provider on rounds this shift.

Obtain an order from the primary healthcare provider on rounds this shift.

The nurse is caring for a client in the outpatient infusion unit. What should the nurse do after administering a chemotherapeutic drug intravenously (IV)? 1. Hang a 250 ml normal saline bag to flush the IV line. 2. Wear shoe covers during disposal of the drug. 3. Place the IV bag and tubing into a chemotherapy waste container. 4. Remove personal protective equipment (PPE) and dispose in a biohazardous container.

Place the IV bag and tubing into a chemotherapy waste container.

A client presents to the emergency department (ED) reporting fever, cough, and malaise. The nurse notes that the client has a rash appearing as vesicles most prominently on the face, palms of the hands, and soles of the feet. In addition to triaging the client as emergent, what should the nurse do? 1. Send the client to the waiting room. 2. Place the client in a negative pressure room. 3. Put a surgical mask on the client. 4. Initiate contact precautions.

Place the client in a negative pressure room.

A visitor is going into the room of a client who is on droplet precautions. Which instruction would the nurse give the visitor? 1. Limit your time in the room to 5 minutes and leave the door open. 2. Avoid contact with the client and any objects in the room. 3. Wear only a mask when in the room. 4. Put on a mask, gown, gloves, and eye shield.

Put on a mask, gown, gloves, and eye shield.

While making rounds, the nurse discovers a small fire in a client's room. What should the nurse do first? 1. Remove the client from the room immediately. 2. Leave the client's room to obtain a fire extinguisher. 3. Instruct the unlicensed assistive personnel (UAP) to pull the fire alarm. 4. Evacuate all clients from the unit.

Remove the client from the room immediately.

The nurse is caring for a client in the emergency department (ED) who fell five feet from a ladder. What is the nurse's priority intervention? 1. Obtain a nursing history. 2. Support the cervical spine. 3. Cleanse and dress the head wound laceration. 4. Splint the right leg fracture.

Support the cervical spine.

These clients have arrived to the emergency department (ED) following an explosion at a local industrial plant. The ED is operating under disaster protocol. Which client should be treated first? 1. The client whose blood pressure is 40 palpable, heart rate 30, and respirations 6. 2. The comatose client with fixed and dilated pupils. 3. The unresponsive client with an open head fracture and visible white matter. 4. The client with a sucking chest wound and tension pneumothorax.

The client with a sucking chest wound and tension pneumothorax.

A client is in the surgical suite to have a left total knee replacement performed. Prior to the surgeon initiating the first incision, what should the circulating nurse ensure the surgical team perform? 1. Surgical scrub 2. Time out 3. Sponge and instrument count 4. Inspection of the surgical site

Time out

The home health nurse is caring for a client with urinary problems. What information should be included when teaching the client how to perform intermittent self catheterization? 1. To be done in an emergency department (ED). 2. Important in treating urinary catheter infections. 3. To be done as a clean procedure. 4. To be done while using sterile gloves.

To be done as a clean procedure.

A community health nurse prepares a presentation about decreasing the risk of the spread of influenza in the community. Which information should the nurse include in the presentation? 1. The flu is transmitted via the influenza vaccine. 2. Use a shirtsleeve when coughing or sneezing if tissue is not available. 3. Tissues are not effective in decreasing the spread of the influenza. 4. Antibiotics are effective in treating influenza.

Use a shirtsleeve when coughing or sneezing if tissue is not available.