SAFETY AND INFECTION CONTROL

A client is entering the chemical dependency unit for treatment of alcohol dependency. Which of the client's possessions should the nurse place in a locked area?

antiseptic mouthwash Explanation: Antiseptic mouthwash commonly contains alcohol and should be kept in a locked area unless labeling clearly indicates that the product does not contain alcohol. A client with an intense craving for alcohol may drink mouthwash that contains alcohol. Personal care items, such as toothpaste, dental floss, and shaving cream, do not contain alcohol, and the client would be allowed to keep them in the room.

A cloth chest restraint has been prescribed for a client who is restless and combative due to alcohol intoxication. What is an appropriate nursing intervention for this client? Check the extremities for circulation based on hospital protocols. Document the client's mental status every shift. Secure the restraints to the bed with knots to ensure the client cannot undo them. During this period of restraint, restrict any family visitation to the client.

Check the extremities for circulation based on hospital protocols. Explanation: Assessment of extremities is essential for distal blood flow. Professional responsibility is to follow policies and procedures by the hospital. Family presence can lessen confusion, tied knots do not allow for quick release in an emergency situation, and documentation of a client in this acute state needs to occur more often than once per shift.

An infant requires cardiorespiratory monitoring. A nurse must locate and clean the necessary equipment, move it into the infant's room, and secure it to the bedside wall-mounting device. Which principles should a nurse use to complete this task safely?

Principles of infection control and ergonomics Explanation: Properly cleaning the monitoring equipment involves infection control. Properly placing and securing the monitor uses ergonomic principles. The principles of geometry and mathematics aren't relevant to safety.

The nurse is caring for a client with a nasogastric tube and in mitt restraints. Which nursing action is required every 1 to 2 hours? Remove restraints and assess skin and circulation. Offer the client sips of clear liquids. Assist the client to the bathroom. Assess cognitive status.

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

A 10-year-old child presents to the emergency department with dehydration. A physician orders 1 L of normal saline solution be administered at a rate of 60 ml/hour. While preparing the infusion, a nurse notices that the I.V. pump's safety inspection sticker has expired. Which action should the nurse take next?

Take the pump out of commission and locate a pump with a valid inspection sticker. Explanation: The nurse shouldn't use any equipment that doesn't have current inspection information. The pump could malfunction, causing harm to the patient. The nurse should remove the pump from service and locate a pump with the proper inspection information.

What is the nurse's initial action when preparing to insert a nasogastric (NG) tube? Apply sterile gloves. Wash hands. Open all necessary kits and tubing. Apply a mask and gown.

Wash hands. Explanation: The first intervention before a procedure is hand washing. Clean gloves are used because the mouth and nasopharynx aren't considered sterile. A mask and gown aren't required. Opening all the equipment is the next step before inserting the NG tube

A client received treatment with cytotoxic medications 24 hours ago. Which precautions are necessary when caring for the client? Wear sterile gloves when emptying bedpans or urinals. Use a bleach solution to clean bedpans or urinals after use. Wear personal protective equipment when handling blood, body fluids, and feces. Provide a urinal or bedpan to decrease the likelihood of soiling linens.

Wear personal protective equipment when handling blood, body fluids, and feces. Explanation: Cytotoxic medications are present in the waste and body fluids of clients for 48 hours after administration. The nurse should wear personal protective equipment when handling blood, body fluids, or feces. Gloves offer minimal protection against exposure. The nurse should wear a face shield, gown, and gloves when exposure to blood or body fluid is likely. Incontinence pads should be placed in the specified trash container, and providing a urinal or bedpan does not protect the nurse caring for the client. A bleach solution will not protect the nurse from exposure to cytotoxic medications and is not necessary.

When caring for the client with hepatitis B, which situation would expose the nurse to the virus? touching the client's arm with ungloved hands while taking a blood pressure contact with fecal material a blood splash into the nurse's eyes disposing of syringes and needles without recapping

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

While hospitalized, a child develops a Clostridium difficile infection. The nurse can anticipate adding which type of precautions for this client? droplet precautions contact precautions airborne precautions standard precautions

contact precautions Explanation: Contact precautions are used for serious illnesses that are easily transmitted by direct client contact or by contact with items in the client's environment. Clostridium difficile infection is an example of an infection that is spread in this manner. Droplet precautions are used for serious illnesses transmitted by large particle droplets. Standard precautions are used for all clients. Airborne precautions are used for suspected illnesses transmitted by airborne nuclei.

A nurse is teaching a new mother how to prevent burns in the home. Which statement by the mother indicates more teaching is required? "I will not hold my infant while drinking coffee." "I will heat my infant's formula in the microwave." "I will set my hot water heater to 49° C (120° F)." "I will keep loose appliance cords tied up on the counter."

contact precautions Explanation: For a client with Clostridium difficile infection, it is imperative to institute contact precautions for the duration of the illness when providing care to the client to minimize the risk of disease transmission. Airborne precautions would be used for a client with an infection, such as tuberculosis, that is transmitted by small droplets that can remain suspended and widely dispersed by air currents. Droplet precautions would be used for a client with an infection, such as diphtheria or rubella, that is transmitted by large-particle droplets that are dispersed into air currents. Protective precautions would be used for a client with compromised immunity as evidenced by a significantly reduced neutrophil count, such as from chemotherapy or immunosuppressive agents.

A visitor to the hospital has a cardiac arrest. When determining to use an automated external defibrillator (AED), the nurse should consider that AEDs are used in cardiac arrest in which circumstances? early defibrillation in cases of ventricular fibrillation early defibrillation in cases of atrial fibrillation pacemaker placement cardioversion in cases of atrial fibrillation

early defibrillation in cases of ventricular fibrillation Explanation: AEDs are used for early defibrillation in cases of ventricular fibrillation. The American Heart Association and Canadian Heart and Stroke Foundation place major emphasis on early defibrillation for ventricular fibrillation and use of the AED as a tool to increase sudden cardiac arrest survival rates

The nurse is completing a sexual history on a client. The client reports a history of having a sexually transmitted infection (STI) that lies dormant in the body and can reoccur, but does not remember the name. Which STI matches the client's description? syphilis gonorrhea herpes chlamydia

herpes Explanation: The nurse is most accurate to identify the herpes infection as the virus can remain dormant in the ganglia of the nerves. Symptoms are usually more severe with the initial outbreak. Subsequent episodes are usually shorter and less intense. The other infections do not have the same characteristics and, if identified, will be documented in the history.

The nurse explains to a family that they cannot go with the client past the doors that separate the public from the restricted area of the operating room suite. What is the purpose of this restriction? separation of the family from the surgical team during the operation protection of the privacy of clients prevention of electrical sparks that could ignite the anesthetic gases maintenance of an aseptic environment to prevent infection

maintenance of an aseptic environment to prevent infection Explanation: The purpose of separating the public from the restricted-attire area of the operating room is to provide an aseptic environment and prevent contamination of the environment by organisms. The client's privacy is protected, but the main purpose is infection control. Anesthetics currently in use do not pose a risk of being ignited.

A nurse is assigned to a client with a cardiac disorder. The nurse should question an order to monitor the client's body temperature by which route? oral rectal axillary tympanic

rectal Explanation: When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take temperature. Using this route could stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. The other options are appropriate routes for measuring the temperature of a client with a cardiac disorder.

When developing the plan of care for a client with suicidal ideation, the nurse should address which priority issue? safety self-esteem stress sleep

safety Explanation: For the client with suicidal ideation, client safety is the priority. The nurse protects the client from self-harm or self-destruction. Although self-esteem, sleep, and stress are common areas that require intervention for a client with suicidal ideation, ensuring the client's safety is the most immediate and serious concern.

A client in early labor is connected to an external fetal monitor. The physician hasn't noted any restrictions on her chart. The client tells the nurse that she needs to go to the bathroom frequently and that her partner can help her. How should the nurse respond? "I'll insert a urinary catheter; then you won't need to get out of bed." "I'll show your partner how to disconnect the transducer so you can walk to the bathroom." "Please press the call button. I'll disconnect you from the monitor so you can get out of bed." "Because you're connected to the monitor, you can't get out of bed. You'll need to use the bedpan."

"Please press the call button. I'll disconnect you from the monitor so you can get out of bed." Explanation: The nurse should instruct the client to use the call button when she needs to use the bathroom. The nurse will need to disconnect the fetal monitor and mark the strip to indicate the activity. If the client's partner disconnects and reconnects the monitor, the nurse can't determine if the readings are accurate. Inserting a catheter without a physician's order or not allowing the client to get out of bed isn't acceptable nursing practice.

Which activity should the nurse recommend to the client on an inpatient unit when thoughts of suicide occur? talking with the nurse playing a card game with other clients engaging in physical activity keeping track of feelings in a journal

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

A client who is paralyzed after a spinal cord injury needs to be transferred to a stretcher. Which assistive device should the nurse use to facilitate this transfer? transfer board lift sheet transfer chair gait belt

transfer board Explanation: A transfer board is made of smooth, rigid, low-friction material and is placed under the client to provide a slick surface. The surface of the board reduces friction and limits the force needed to move the client from the bed to a stretcher. A gait belt would be contraindicated because the client is unable to use the leg muscles because of paralysis. A lift sheet would be used in bed to reposition the client. It would not be helpful when transferring the client from the bed to the chair. A transfer chair converts to a stretcher. This type of device is not required for the client.

The nurse is precepting a graduate nurse and preparing to give infant immunizations. The preceptor asks the graduate, "Infant injections should only be given in which muscle?" What is the best response by the graduate nurse? "deltoid" "gluteus maximus" "vastus lateralis" "rectus femoris"

vastus lateralis" Explanation: The vastus lateralis muscle is preferred until the deltoid muscle has developed adequate mass (approximately age 36 months). Medications are injected into the bulkiest part of the vastus lateralis thigh muscle, which is the junction of the upper and middle thirds of this muscle. The vastus lateralis is the preferred site for IM injection in infants under 12 months of age. The rectus femoris, and gluteus maximus sites are not developed as an infant.

An elderly client has been admitted to the medical-surgical unit from the postanesthesia care unit. While the nurse is off the floor, the client falls out of bed and fractures the right leg and right wrist. The nurse finding the client states, "The side rails were down and the bed was in the high position." The client's family files legal charges against the nurse and the hospital. Which charge most accurately reflects the nurse's actions? battery comparative negligence negligence collective liability

negligence Explanation: The position of the client's bed indicates negligence, a general term that denotes conduct lacking in due care. Collective liability stems from cooperation by several manufacturers in a wrongful activity. Comparative negligence holds the injured parties accountable for their fault in the injury. Battery involves harmful or unwarranted contact with the client.

Following a sexual assault the client tells the nurse that she is on long-lasting birth control and has no intention of taking any legal action against her assailant. The nurse advises the client that she stills needs follow-up care for early detection of which problem?

sexually transmitted disease Explanation: The post-rape examination is important for detecting the possibility of sexually transmitted disease, which can be spread through rape. The client should also be examined for infection that can result from trauma. Additionally, if the victim or the rapist was not using a contraceptive, postcoital contraceptive methods should be discussed. The information provided does not indicate anxiety or physical injury, such as periurethral tears, and these are not the primary reason for the examination. Menstrual difficulties are not a common result of rape.

The nurse develops a health education program about preventing the transmission of hepatitis B. The nurse evaluates that the teaching has been effective when the participants identify which activities to be high risk for acquiring hepatitis B? sharing needles for drug use ingestion of contaminated seafood frequent use of marijuana ingestion of large amounts of acetaminophen

sharing needles for drug use Explanation: Sharing needles is associated with increased incidence of blood-borne diseases such as hepatitis B. Hepatitis B is not spread through marijuana use. Acetaminophen taken in large amounts can cause severe hepatic necrosis but does not cause hepatitis B. Contaminated seafood is responsible for transmission of hepatitis A.

A client is 4 days postoperative from a tibia fracture and has a long leg cast. The nurse is conducting initial teaching for walking with crutches. What is the most important activity for the nurse to encourage the client to do prior to discharge from the hospital? conduct exercises in bed to strengthen the upper extremities, as this will assist the client in crutch use. sit up straight in a chair to develop the back muscles, as this will help the client walk with crutches. while walking, do weight bearing on the cast to increase balance. keep the affected limb in extension and abduction at all times.

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

At the beginning of a shift, the team leader notices that all of the I.V. antibiotics for a client are still in the medication room. What is the team leader's first action? Ask the nurse assigned to this client about the medications. Ask the client if medication was received during the previous shift. Notify the unit's nurse manager. Return the medications to the pharmacy to reduce hospital expenses.

Ask the nurse assigned to this client about the medications. Explanation: The team leader should attempt to clarify this matter with the assigned staff first. The client would not be an accurate source of information regarding the I.V. medications. Returning the supplies is secondary to ensuring that the client received the required medications.

A client with stage II Alzheimer's disease is admitted to the short stay unit after cardiac catheterization that involved a femoral puncture. The client is reminded to keep their leg straight. A knee immobilizer is applied, but the client repeatedly attempts to remove it. The nurse is responsible for three other clients who underwent cardiac catheterization. What's the best step the nurse can take? Ask the staffing coordinator to assign a nursing assistant to sit with the client. Apply wrist restraints. Sedate the client. Continually remind the client not to move their leg and to leave the immobilizer alone.

Ask the staffing coordinator to assign a nursing assistant to sit with the client. Explanation: The nurse should ask the staffing coordinator to assign a nursing assistant to sit with the client. This action promotes client safety while avoiding restraint use. Applying wrist restraints doesn't prevent injury to the lower leg. Also, restraints should be applied only after other less restrictive measures have been attempted. A client with stage II Alzheimer's disease has memory impairment that impedes their ability to remember repeated instruction. Sedation isn't indicated for this client

While out of bed walking, a client reports dizziness and requests to go back to the room. The nurse obtains the blood pressure machine and obtains vital signs on the client. The client's pulse is 50 and the blood pressure machine reads 80/40 mmHg. The nurse notes the client is scheduled to receive verapamil and atenolol. Which actions by the nurse are best? Select all that apply. Give the medications and check vital signs later. Call the supervisor and ask what to do. Hold the medications. Call the healthcare provider and provide a report of the events and vital signs. Give the scheduled medications.

Hold the medications. Call the healthcare provider and provide a report of the events and vital signs. Explanation: Considering the ordered medications verapamil and atenolol, the pulse rate, and blood pressure, the medications should be held and the healthcare provider should be notified about the events and vital signs of the client. The healthcare provider will decide whether to give the medication or hold at this time. Verapamil and atenolol can cause slow heartbeat, so if the heartbeat is already slow, the medications should be held.

The home health nurse visits an older adult client and their spouse to discuss home safety prior to discharge from the hospital. What information should the nurse focus on to optimize safety? "Your spouse should avoid unsteady ladders and electrical appliances." "Test your smoke alarms, and avoid handling flammable liquids." "Be sure to properly store all plastic bags and install handrails on steps." "It's important to have good lighting and clear, even flooring surfaces."

It's important to have good lighting and clear, even flooring surfaces." Explanation: The home health nurse should focus safety teaching on factors that promote mobility, such as having adequate lighting, removing clutter from paths, and using nonskid bathroom surfaces. At least one safety concerns in each of the other options is more relevant to other age groups; plastic bags and electrical appliances, for instance, present safety concerns for toddlers and children.

An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. What should the nurse advise the mother to do? Remove any unsafe items from the area in which the infant is mobile. Confine the infant to one room in the apartment. Keep the infant in the splint at night, removing it during the day. Notify the health care provider (HCP) immediately to adjust the treatment plan.

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

The client in balanced suspension traction is transported to surgery for closed reduction and internal fixation of a fractured femur. What should the nurse do when transporting the client to the operating room? Call the surgeon to request a prescription to temporarily remove the traction. Send the client on the bed with extra help to stabilize the traction. Transfer the client to a cart with manually suspended traction. Remove the traction, and send the client on a cart.

Send the client on the bed with extra help to stabilize the traction. Explanation: The nurse should send the client to the operating room on the bed with extra help to keep the traction from moving to maintain the femur in the proper alignment before surgery. Transferring the client to a cart with manually suspended traction is inappropriate because doing so places the client at risk for additional trauma to the surrounding neurovascular and soft tissues, as would removing the traction. The surgeon need not be called because the decision about transferring the client is an independent nursing action.

A nurse is caring for a client returning from cardiac catheterization. The nurse helps transfer the client back to bed. Which transfer technique uses appropriate ergonomic principles? The nurse raises the bed for transfer, maintains a wide base of support during transfer, and lowers the bed before leaving the room. The nurse explains the procedure to the client and grabs the client under the arms to pull them over to the bed. The nurse maintains a narrow base of support during transfer and encourages the client to hold onto the staff members if the client is frightened. The nurse lowers the bed for transfer. The nurse raises the bed before leaving the room, making sure to place the call light within reach.

The nurse raises the bed for transfer, maintains a wide base of support during transfer, and lowers the bed before leaving the room. Explanation: The nurse should raise the bed for transfer, maintain a wide base of support during transfer, and lower the bed before leaving the room. Lowering the bed for a transfer places the nurse at risk for injury. Raising the bed before leaving the room places the client at risk for injury. The nurse should maintain a wide base of support for transfers and shouldn't encourage the client to grab or hold onto staff members during transfers. Although the nurse should explain the procedure to the client, the nurse shouldn't grab the client under the arms. This action could cause shoulder injury or nerve damage. The nurse shouldn't pull a client during transfers; doing so places the client at risk for skin-shear injuries.

The nurse on a gerontology unit will be admitting several new clients to the unit over the next few hours. There are two shared rooms and one single-client room currently vacant on the unit. Which client should be placed in the single-client room? a client who has developed hypokalemia due to Clostridium difficile-related diarrhea a terminally ill client with chronic heart failure who is accompanied by several family members a client who is being readmitted following the dehiscence of an abdominal surgical incision a previously healthy client who has been diagnosed with delirium of unknown etiology and who is agitated

a client who has developed hypokalemia due to Clostridium difficile-related diarrhea Explanation: For reasons of infection control, a client with Clostridium difficile-related diarrhea must be housed in a single room. This infection control measure would supersede the need to accommodate visitors. It is ideal for a client who is agitated to be in a single-client room, but the necessity of infection control would override this factor.

When discharging a 5-month-old infant from the hospital, the nurse checks to see whether the parent's car restraint system for the infant is appropriate. Which restraint system would be safest? A rear-facing infant safety seat in the front passenger seat A front-facing convertible car seat in the middle of the back seat A front-facing convertible car seat in the back seat next to the window A rear-facing infant safety seat in the middle of the back seat

A rear-facing infant safety seat in the middle of the back seat Explanation: Infants from birth to 20 lb (9.1 kg) and younger than age 1 must be in a rear-facing infant or convertible seat in the back seat, preferably in the middle. Infants and small children should never be placed in the front seat because of the risk of injuries from a breaking front windshield and an expanding airbag. Positioning a car seat next to the window isn't preferred.

A school-age child has just spilled hot liquid on his arm, and a 4-in (10-cm) area on his forearm is severely burned. His mother calls the emergency department. What should the nurse advise the mother to do? Cover the burned area with an antibiotic cream. Apply cool water to the burned area. Keep the child warm. Call 911 to transport the child to the hospital.

Apply cool water to the burned area. Explanation: To prevent further injury to the skin, the mother should apply cool water to the burn site. Doing so causes vasoconstriction, retards further damage to tissues, and decreases fluid loss. Keeping the child warm promotes vasodilation, increases fluid loss, and decreases blood pressure and, thus, circulation to the area. Applying ointment to the burn is contraindicated because it does not allow healing to occur and may need to be removed in the hospital. Only a clean cloth should be used to cover the wound to prevent contamination or decrease pain or chilling. If only the arm is burned, a call to 911 for emergency care is not necessary, but the mother should seek health care services immediately.

A client is being discharged from same-day surgery. Which statement indicates that the client does not understand postoperative instructions about transportation to home? "I can drive myself home after surgery." "My son will be here at noon to take me home." "My husband is taking the day off from work to drive me home." "I am taking a taxi home, and my daughter will meet me at home."

"I can drive myself home after surgery." Explanation: The client admitted for same-day surgery should not drive home after the surgical procedure because it is unsafe. Even without an anesthetic, the surgical event can be more stressful than anticipated. It is acceptable to have someone arrive after the surgery has started to take the client home. A taxi is permissible but not desirable.

The nurse is providing teaching to an expectant mother about breastfeeding. What statement made by the mother would require immediate follow-up by the nurse? "I was treated for gonorrhea 2 years ago." "I was told I had a heart murmur when I was a child." "I have been HIV positive for 4 years." "I had difficulty becoming pregnant because of endometriosis."

"I have been HIV positive for 4 years." Explanation: A mother who has HIV is strongly discouraged from breastfeeding because of the risk of transmitting the infection to the neonate. Newborns born to HIV-positive mothers are generally treated with the antiviral medication zidovudine for the first 6 weeks after birth. A mother with a history of endometriosis may breastfeed and should not have symptoms of the condition until menses resume. Having a heart murmur may be a benign condition in childhood and is not a contraindication for breastfeeding. A past history of gonorrhea is not a contraindication to breastfeeding.

A charge nurse is completing client assignments for the nursing staff on the pediatric unit. Which client would the nurse refrain from assigning to a pregnant staff member? a 2-year-old with Kawasaki's disease an 8-year-old with Rubella a 6-year-old with ringworm a 3-month-old with Roseola

an 8-year-old with Rubella Explanation: Rubella (German measles) has a teratogenic effect on the fetus. An infected child must be isolated from pregnant women. Ringworm is caused by a fungal infection on the skin. Standard hand hygiene is necessary. Kawasaki's disease is an autoimmune disease in which blood vessels become inflamed. Roseola is a virus transferred by oral secretions.

A client arrives on the psychiatric unit exhibiting extreme excitement, disorientation, incoherent speech, agitation, frantic and aimless physical activity, and grandiose delusion. Which nursing diagnosis takes highest priority for this client at this time? ineffective coping risk for injury hopelessness disturbed personal identity

risk for injury Explanation: This client is at increased risk for injury because of severe hyperactivity, disorientation, and agitation. Although ineffective coping, hopelessness, and disturbed personal identity also are appropriate diagnoses, the client's safety takes highest priority. The nurse should take immediate action to protect the client from injury.

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 hot water bottles or heating pads." "I will avoid kitchen activities." "I will inspect my skin daily for pressure points and injury." "I will carefully test the temperature of my bathwater."

"I will avoid kitchen activities." Explanation: Safety concerns are essential for a client with sensory impairment. Water temperature should be tested carefully, hot water bottles should be avoided, and the skin should be inspected regularly. Independence and self-care are also important; the client should not be instructed to avoid kitchen activities out of fear of injury.

A client presents to the emergency department (ED) with suicidal thoughts and a long-standing history of major depression. The nurse completes a mental status assessment and deems that the physician needs to see the client immediately. Which action would be most appropriate for the nurse to take next? Ask the client to agree to remain in the room until the nurse returns. Arrange for another nurse to check on the client in 10 minutes. Restrain the client to the gurney in the examining room. Call the physician from a phone in the examining room.

Call the physician from a phone in the examining room. Explanation: Remaining with a suicidal client in an unsafe environment is the best intervention to prevent a suicidal act, and calling the doctor from the exam room is the correct answer. Asking the client to agree to remain in the room until the nurse returns leaves the patient vulnerable. The client should not be left alone in a suicidal state because the ED is not secure and numerous risks to safety are present. Similarly, although close observation is appropriate in a locked inpatient unit, the ED is not a secure environment and threats to safety are present even if monitored every 10 minutes. Restraints are an unsafe and inappropriate measure to prevent a client's suicide attempt.

A client presents to the emergency department (ED) with suicidal thoughts and a long-standing history of major depression. The nurse completes a mental status assessment and deems that the physician needs to see the client immediately. Which action would be most appropriate for the nurse to take next? Call the physician from a phone in the examining room. Arrange for another nurse to check on the client in 10 minutes. Restrain the client to the gurney in the examining room. Ask the client to agree to remain in the room until the nurse returns.

Call the physician from a phone in the examining room. Explanation: Remaining with a suicidal client in an unsafe environment is the best intervention to prevent a suicidal act, and calling the doctor from the exam room is the correct answer. Asking the client to agree to remain in the room until the nurse returns leaves the patient vulnerable. The client should not be left alone in a suicidal state because the ED is not secure and numerous risks to safety are present. Similarly, although close observation is appropriate in a locked inpatient unit, the ED is not a secure environment and threats to safety are present even if monitored every 10 minutes. Restraints are an unsafe and inappropriate measure to prevent a client's suicide attempt.

The nurse is planning care for a client with severe postoperative pain. There is a prescription for morphine written as "10 mg MSO4" on the medical record. What should the nurse do first? Obtain an intravenous infusion system. Contact the pharmacy department. Contact the health care provider (HCP) who prescribed the medication. Prepare the medication for administration.

Contact the health care provider (HCP) who prescribed the medication. Explanation: The nurse should first contact the HCP because the prescription for the morphine is not complete. The Joint Commission of the United States and the Institute for Safe Medication Practices Canada recommend not to use MSO4 because it can apply to morphine as well as to magnesium sulfate. There is no mention of an IV system being needed. The morphine should not be in the medication cabinet because the prescription is not complete. Although pharmacy may offer a suggestion as to what the medication prescribed is, the best means to confirm the intent of the prescription is to contact the HCP who wrote the prescription.

A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test? Place a cap over the client's head. Immobilize the neck before the client is moved onto a stretcher. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. Administer a sedative as ordered.

Determine whether the client is allergic to iodine, contrast dyes, or shellfish. Explanation: Because CT commonly involves use of a contrast agent, the nurse should determine whether the client is allergic to iodine, contrast dyes, or shellfish. Neck immobilization is necessary only if the client has a suspected spinal cord injury. Placing a cap over the client's head may lead to misinterpretation of test results; instead, the hair should be combed smoothly. The physician orders a sedative only if the client can't be expected to remain still during the CT scan

A parent calls the health clinic and tells the nurse that the toddler was found with an open and empty bottle of acetaminophen. The parent asks the nurse what to do. What is the nurse's priority intervention? Give the parent instructions on how to call poison control. Have the parent give the child syrup of ipecac. Tell the parent to get the child to drink a glass of milk. Determine whether the parent knows cardiopulmonary resuscitation (CPR)

Give the parent instructions on how to call poison control. Explanation: The parent should call poison control and ask what immediate steps should be taken to treat this ingestion. Home administration of syrup of ipecac is no longer recommended. Milk is not an antidote for acetaminophen toxicity. Asking about CPR is not appropriate since it would distract from the immediate interventions needed.

A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement? Related to visual field deficits Related to difficulty swallowing Related to psychomotor seizures Related to impaired balance

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

A nurse manager is auditing the nursing unit's adherence to infection control practices. Which observation causes the nurse manager to be most concerned that the clients on the unit are at risk for infection? A nurse does not use sterile scissors to cut the tape for a wound dressing. A nurse does not wear a mask when entering the room of a client on contact precautions. Several nurses fail to perform hand hygiene between clients. A client receives a prophylactic antibiotic 20 minutes late.

Several nurses fail to perform hand hygiene between clients. Explanation: Hand hygiene is the single most important infection prevention and control practice. A mask is not necessary for clients on contact precautions, and tape does not have to be cut with sterile scissors. Although administering the antibiotic late is cause for concern, it does not present as big a risk as failure to perform hand hygiene.

A client has an abdominal wound that requires irrigation. Where should the nurse place the client's old dressing after removal? in the trash in the hallway in the bathroom trash can a biohazardous trash container in the trash next to the client's bed

a biohazardous trash container Explanation: A biohazardous trash container is used to dispose of trash that contains liquid or semiliquid blood or other potentially infective material. The old dressing contains blood and other potentially infective material and should be placed into a biohazardous trash container. The old dressing should not be placed in the trash in the bathroom, the hallway, or next to the client's bed.

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 toddlers will always chase a ball that rolls into the street. accidents are the leading cause of death among toddlers. toddlers can distinguish right from wrong. the risk for homicide is highest among toddlers.

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

A nurse is orienting a new nurse to the labor and delivery unit. Which action by the new nurse regarding a neonate's security requires intervention by the preceptor? allowing volunteers to return neonates to the nursery affixing a security bracelet that monitors movement to a neonate affixing matching identification bands to the parents and neonate at birth positioning a rooming-in neonate's bassinet toward the center of room rather than near the door to the hallway

allowing volunteers to return neonates to the nursery Explanation: The new nurse requires additional teaching if allowing volunteers to return neonates to the nursery. Unit staff members won't likely recognize volunteers, whose assignments vary with each shift. Affixing matching identification bands at birth, positioning a rooming-in neonate's bassinet toward the center of the room, and affixing security bracelets are appropriate security measures.

While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. The nurse should first: ask what the client was doing out of bed. activate the "Emergency Response" button. assess the client's current condition and vital signs. assist the client back to bed.

assess the client's current condition and vital signs. Explanation: The nurse's first priority is to complete an assessment of the client including assessment of airway, breathing, circulation, and vital signs as well as any change in level of consciousness or obvious injury.The nurse should not move the client or assist the client back to bed until after an assessment has been completed to prevent further injury.While it may be helpful to know what the client was doing out of bed in order to assess for potential confusion, the client's immediate safety is first priority.The nurse would not activate the "Emergency Response" button until an initial assessment was done to determine the need.

The nurse is administering medications to a client with advanced Alzheimer's dementia who is confused to person, place, and time. Prior to administering the medication, what action should the nurse perform to verify the client's identity? Ask another staff member the name of the client in the room. Ask the client to state name and birthdate, then compare it to the medication administration record. Check the name listed on the unit board for the room. Compare the name and ID number on the client's wristband to the medication administration record.

Compare the name and ID number on the client's wristband to the medication administration record. Explanation: The nurse should compare the name and ID number on the client's wristband to the medication administration record. As the client is not oriented to person, place, or time, it is not appropriate to verify identity by asking the client to state his or her name and birthdate. Checking the name listed on the unit board for the room does not ensure that the client in the room is the correct client. Asking another staff member the name of the client in that room does not ensure adequate verification of identity.

A neonate is experiencing respiratory distress and is using a neonatal oxygen mask. An unlicensed assistive personnel has positioned the oxygen mask as shown. The nurse is assessing the neonate and determines that the mask: is appropriate is positioned too low. is too large. is too small.

is appropriate Explanation: The mask is appropriate because it covers the nose and mouth and fits snugly against the cheeks and chin. The mask is not too low. Masks that are too large may cover the eyes. Masks that are too small obstruct the nose

Which use of restraints in a school-age child should the nurse question? to ensure the child's comfort or safety to facilitate examination to substitute for observation to aid in carrying out procedures

to substitute for observation Explanation: Restraints should never be used as a punishment or as a substitute for observation because if a child is at risk for self-harm when left alone, the child requires one-on-one observation. Ensuring the child's comfort or safety (restraining to keep an I.V., drainage tube, or orthopedic device in place), facilitating examination, and carrying out procedures are all valid reasons for restraint. Restraining devices aren't without risk and must be checked and documented every 1 to 2 hours.

The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse observes which action? placement of bloody sheets in a container designated for contaminated linens use of protective goggles during a cesarean birth wearing of sterile gloves to bathe a neonate at 2 hours of age disposal of used scalpel blades in a puncture-resistant container

wearing of sterile gloves to bathe a neonate at 2 hours of age Explanation: One of the staff members needs further instructions when the nurse observes the staff member wearing sterile gloves to bathe a neonate at 2 hours of age. Clean gloves should be worn, not sterile gloves. Sterile gloves are more expensive than clean gloves and are not necessary when bathing a neonate. Wearing protective goggles during a cesarean birth is a standard blood precaution. Bloody sheets should be placed in a designated container. Scalpel blades, needles, syringes, and other equipment used during birthing should be disposed of safely in appropriate, labeled containers.

Which measure should the nurse include in the plan of care for a client with alcohol withdrawal delirium? using restraints continuously informing the client about alcohol treatment programs touching the client before saying anything remaining with the client when the client is confused or disoriented

remaining with the client when the client is confused or disoriented Explanation: The client with alcohol withdrawal delirium should not be left unattended when confused, disoriented, or hallucinating. Injury or unintentional suicide is a possibility when the client attempts to get away from hallucinations. Restraints are used only when the client loses control and is a danger to herself or others. Touching the client before saying anything is an additional stimulus that would most likely add to the client's agitation. Informing the client about the alcohol treatment program while the client is delirious is inappropriate and shows poor nursing judgment. The client should be given information about alcohol treatment when the withdrawal symptoms are lessening and the client can comprehend the information.

A client arrives on the psychiatric unit exhibiting extreme excitement, disorientation, incoherent speech, agitation, frantic and aimless physical activity, and grandiose delusion. Which nursing diagnosis takes highest priority for this client at this time? disturbed personal identity risk for injury hopelessness ineffective coping

risk for injury Explanation: This client is at increased risk for injury because of severe hyperactivity, disorientation, and agitation. Although ineffective coping, hopelessness, and disturbed personal identity also are appropriate diagnoses, the client's safety takes highest priority. The nurse should take immediate action to protect the client from injury.

quiz 4 number 5 A client reports to a physician's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education? "The test may be mildly uncomfortable." "I may experience itching and irritation at the site of the testing." "I'll go directly to the pharmacy with my epinephrine pen prescription." "If I notice tingling in my lips or mouth, gargling may help the symptoms.

"If I notice tingling in my lips or mouth, gargling may help the symptoms." Explanation: The client requires further teaching if they state they will gargle to help alleviate tingling in the lips or mouth. Allergy testing introduces potentially irritating substances to the client. Tingling in the mouth, lips, or throat indicates the onset of a severe reaction and the need for immediate medical intervention. The testing may cause irritation and itching at the test site. The physician may order an epinephrine pen for the client to self-administer epinephrine if they experience an allergic reaction away from the office setting.

Which situations should a supervisor consider in making assignments for nurses in the neonatal unit? A nurse with young children shouldn't care for a neonate whose mother has gonorrhea. A pregnant nurse shouldn't care for a neonate with cytomegalovirus (CMV). A nurse with young children shouldn't care for a neonate with erythema toxicum. A pregnant nurse shouldn't care for a neonate whose mother was positive for human immunodeficiency virus (HIV).

A pregnant nurse shouldn't care for a neonate with cytomegalovirus (CMV). Explanation: CMV exposure can affect the fetus; women who are pregnant should avoid contact with CMV-positive clients. HIV is transmitted via blood and body fluids; all staff should take contact precautions. When a mother has gonorrhea, a nurse should administer eye prophylaxis to the neonate to prevent neonatal ophthalmic infection. It isn't a concern for staff. Erythema toxicum is a common rash in infancy; communicability isn't a concern.

A client is on isolation precautions for a hospital-acquired infection, and the client's visitors are not following the posted hand hygiene protocol. What is the nurse's best action? Explain to visitors the importance to the client of consistent hand hygiene. Post "do not enter" and "report to the nurse's desk" signs on the hospital door. Document this for the insurance company to bill the client. Report this to the healthcare provider to request an order restricting visitors.

Explain to visitors the importance to the client of consistent hand hygiene. Explanation: The nurse should teach the client and visitors of the need to practice consistent hand hygiene. Hand hygiene by visitors reduces the risk of adding a secondary infection being transmitted to the client. Requesting visitor restrictions and contracting the insurance company are inappropriate actions. Posting "do not enter" signs brings attention but is not the most important action.

What should the nurse do to prevent catheter-associated urinary tract infection? Select all that apply. Maintain a closed drainage system. Recommend the health care provider prescribe antibiotics. Change the catheter daily. Encourage the client to drink 3,000 mL of fluids a day. Provide perineal care at least once a day.

Maintain a closed drainage system Encourage the client to drink 3,000 mL of fluids a day. Provide perineal care at least once a day. Explanation: Catheter-associated urinary tract infection is the most frequent type of health care-acquired infection (HAI) and represents as much as 80% of HAIs in hospitals. The nurse should provide meticulous perineal care at least once a day, maintain a closed drainage system, and encourage the client to obtain an adequate fluid intake. It is not necessary to change the catheter daily. It is recommended that long-term use of an indwelling urinary catheter be evaluated carefully and other methods considered if the catheter will be in place longer than 2 weeks. It is not necessary to request a prescription for antibiotics as the client does not currently have an infection.

The staff of an outpatient clinic has formed a task force to develop new procedures for swift, safe evacuation of the unit. The new procedures haven't been reviewed, approved, or shared with all personnel. When a nurse-manager receives word of a bomb threat, the task force members push for evacuating the unit using the new procedures. Which action should the nurse-manager take? Tell staff members to use whatever procedures they feel are best. Ask staff members to quickly meet among themselves and decide what procedures to follow. Tell staff members to assemble in the staff lounge, where she will quickly gather opinions about evacuation procedures before deciding what to do. Determine that the procedures currently in place must be followed and direct staff to follow them without question.

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

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

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

A client has a coxsackie B (viral) or trypanosomal (parasite) infection. The nurse should further assess the client for which health problem?

myocarditis Explanation: Intracellular microorganisms, such as viruses and parasites, invade the myocardium to survive. These microorganisms damage the vital organelles and cause cell death in the myocardium. The myocardium becomes weak, leading to heart failure; then T lymphocytes invade the myocardium in response to the viral infection. The T lymphocytes respond to the viral infection by secreting cytokines to kill the virus, but they also kill the virus-infected myocardium. Myocardial infarction, renal failure, and liver failure are not direct consequences of a viral or parasitic infection.

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? isolating the agitated client and offering sedation to calm the behavior removing the other clients from the area until this client settles down offering the client a less-stimulating area in which to calm down ensuring the safety of this client and other clients on the unit

ensuring the safety of this client and other clients on the unit Explanation: Ensuring the safety of this client and other clients on the unit is the nurse's immediate priority. Moving the agitated client to a less-stimulating environment, isolating the client, or sedating the client address the client's needs but don't address those of the other clients. Removing other clients from the area until the agitated client calms down addresses the safety of the other clients without addressing the needs of the agitated client.

The nurse is managing care for a group of clients on a busy medical-surgical unit. What is the best way for the nurse to prevent errors? informing the client of the Patient's Bill of Rights notifying the Occupational Safety and Health Administration (OSHA) of workplace violations identifying incorrect dosages or potential interactions of ordered medications not questioning a healthcare provider order because the healthcare provider is ultimately responsible for the client outcome

identifying incorrect dosages or potential interactions of ordered medications Explanation: The nurse must be knowledgeable about drug dosages and possible interactions when administering medications and must follow appropriate policies to correct dosage errors or prevent potential interactions. The nurse is responsible for questioning unclear or ambiguous healthcare provider orders and should never carry out an order if uncomfortable. OSHA establishes comprehensive safety and health standards, inspects workplaces, and requires employers to eliminate safety hazards, but notifying OSHA of medication errors doesn't resolve the problem. The client should be aware of the rights of a client, but that awareness doesn't play a key role in error prevention.

The nurse is planning care for a toddler with a seizure disorder. Which item in the care plan should the nurse revise? oxygen mask and bag system at bedside lorazepam for seizure lasting longer than 5 minutes padded tongue blade at the bedside padded side rails

padded tongue blade at the bedside Explanation: The nurse should revise a care plan that includes padded tongue blades. Nothing should be placed in the mouth during a seizure. Padded side rails will protect the child from injury during a seizure. The bag and mask system should be present in case the child needs oxygen during a seizure. Most seizures resolve in under 5 minutes. If they do not, then a dose of lorazepam can be administered. The healthcare provider will prescribe the correct dosage for weight and the parameters for administering.

A parent of a 9-year-old-child scheduled to have surgery expresses concern about the potential for postoperative infection. A nurse provides the parent with information about the measures taken to maintain surgical asepsis. Typical surgical asepsis involves: using sterile surgical scrubs. preoperative cleansing of jewelry worn by the surgical team. applying bandages to cover any wounds surgical team members have. performing a preoperative surgical scrub for at least 3 to

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

The nurse is admitting four clients with infections to the medical-surgical unit, but only one negative pressure room is available. Which client is it most appropriate to assign to the negative pressure room? a client with toxic shock syndrome (TSS) with a temperature of 102.4°F (39.1°C) a client with a cough who may have tuberculosis (TB) a client with a wound infected with vancomycin-related enterococci (VRE) a client with diarrhea caused by clostridium difficile (C. difficile)

a client with a cough who may have tuberculosis (TB) Explanation: The client with suspected TB needs to have airborne precautions and a negative pressure room. Clients with C. difficile and VRE require contact precautions and should ideally be placed in private rooms, but could be placed in rooms with other clients with the same diagnosis. Standard precautions are required for the client with TSS

A client is preparing for discharge from the emergency department after sustaining an ankle sprain. The client is instructed to avoid weight bearing on the affected leg and is given crutches. After instruction, the client demonstrates proper crutch use in the hallway. What additional information is most important to know before discharging the client? whether pets are present in the home whether the client needs to navigate stairs routinely at home whether the client drives a car with a stick shift whether the client parks the car on the street

whether the client needs to navigate stairs routinely at home Explanation: Knowing whether the client must routinely navigate steps at home is most important. If the client must navigate steps, special crutch-walking techniques must be taught to safely navigate the stairs. Although pets, parking on the street, and driving a car with a stick shift can pose problems for the client, these factors aren't important to know before discharging the client with crutches.

A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement made by the client about safer sex practices for persons with HIV is accurate? "Contraceptive methods, such as hormonal contraceptives, implants, and injections, are recommended for me to prevent HIV transmission." "The only safe sex my partner and I can practice is hugging, petting, and mutual masturbation." "A latex condom provides the best protection against HIV transmission during sexual intercourse." "If both sexual partners are HIV-positive, unprotected sex is permitted."

A latex condom provides the best protection against HIV transmission during sexual intercourse." Explanation: A latex condom with provides the best protection against HIV transmission during sexual intercourse. The nurse should caution the client not to have unprotected sex because continued exposure to HIV in a seropositive client may hasten the course of the disease or result in infection with another strain of HIV. Hormonal contraceptives, implants, and injections offer no protection against HIV transmission. Safe sex practices include hugging, petting, mutual masturbation, and protected sexual intercourse. Abstinence is the most effective way to prevent transmission

The adult daughters of an older adult client inform the nurse that they fully expect their father to be combative after surgery. Preoperatively, they request that the nurse put all four side rails up and use restraints to keep him safe. What should the nurse tell the daughters? "Certainly; we will want to be sure to keep your father safe, too." "Restraint use is prohibited at our hospital at all times." "We will call the health care provider to get a prescription right away." "We will first try to keep him safe without restraint."

We will first try to keep him safe without restraint." Explanation: A least-restraint environment should always be provided as much as possible. Nursing staff are required to attempt lesser restrictive alternatives (e.g., use of family or sitter, reorientation, distraction, or a toileting schedule) prior to notifying the provider of the need for restraints. Nursing staff are also required to document clinical conditions requiring restraint, lesser restrictive alternatives attempted, and client/family education provided regarding restraint use. Provider prescriptions for restraints must be time limited and specific regarding the type of restraint. Additionally, if restraints are implemented, nursing staff must monitor clients for safety (including skin checks and range of motion) and provide frequent food/fluids/toileting.

A client who has been prescribed nitroglycerin, metoprolol, and furosemide is dizzy and has a blood pressure of 84/50 mm Hg. Which action should the nurse take when the medications are scheduled to be provided? Administer the furosemide and metoprolol, and withhold the nitroglycerin. Withhold the medications, and notify the health care provider. Administer the nitroglycerin and metoprolol, and withhold the furosemide. Ensure the client takes medications while lying in bed.

Withhold the medications, and notify the health care provider. Explanation: The medications should be withheld and the health care provider notified because each of these medications has the potential to lower the client's blood pressure. Administering them together when the client is already hypotensive may severely lower the client's blood pressure. Although remaining in bed is the safest for the client at this time, the nurse should not administer these medications regardless of the client's positioning.

A client who has been sexually assaulted is admitted to the emergency department (ED). Which is the most important initial statement by the nurse? "Did you know the person who did this to you?" "I'll get the emergency rape kit." "I'll stay with you while you're here." "Don't worry, trained responders are coming."

"I'll stay with you while you're here." Explanation: The priority of care for the client is safety. Staying with the client at all times is a priority. The perpetrator most likely threatened the victim that if she/he informed anyone about the incident, the rapist will severely harm or kill the victim. Staying with the client also support development of trust of the nurse by the client. The question regarding who is the perpetrator is within the realm of the authorities—not the nurse. Leaving the ED to obtain the rape kit is not the safety priority as staying with the client at all times. This action can be delegated to another individual. Telling an individual to "not worry" is nontherapeutic communication and will not allay the fears of the client who has undergone the trauma of a physical sexual assault.

The nurse is performing a surgical dressing change and drops a sterile gauze on the bedside table outside the sterile dressing tray's field. What would be the appropriate action by the nurse? Ask an unlicensed assistive personnel to obtain another sterile gauze from the supply room. Leave the room to obtain another sterile gauze dressing. Use sterile gloves to put the gauze back on the dressing tray. Place the noncontaminated side of the gauze next to the wound.

Ask an unlicensed assistive personnel to obtain another sterile gauze from the supply room. Explanation: Asking the unlicensed assistive personnel to obtain a new sterile gauze from the supply room demonstrates that the nurse is aware of the contamination of the gauze and that it should not be used. The nurse would not leave the room as this would also cause a break in sterile technique. Using sterile gloves to place the gauze back on the tray contaminates both the sterile gloves and the sterile dressing tray. Using the dressing with the noncontaminated side next to the wound puts the client at risk for infection.

An infant received the wrong medication dose. What is the charge nurse's role in following up on the incident? Suggest that the nurse who administered the medication speak to the hospital lawyer. Objectively assess the circumstances surrounding the error. Make sure the nurse has liability insurance. Send the nurse to a medication administration course.

Objectively assess the circumstances surrounding the error. Explanation: The charge nurse should objectively assess the circumstances surrounding the medication administration error. After completing the assessment, the charge nurse should develop a plan with the nurse to prevent future errors. The charge nurse doesn't need to suggest that the nurse speak with hospital lawyer or make sure the nurse has liability insurance until the circumstances surrounding the error are investigated. Nothing suggests that the nurse needs to attend a medication administration course.

The unlicensed assistive personnel (UAP) records a capillary blood glucose of 253 mg/dL (14.04 mmol/L) and the nurse administered insulin for coverage to the client. The UAP reports to the nurse that the blood glucose was incorrect. What actions should the nurse take? Select all that apply. Observe the client for hypoglycemia. Obtain a current blood glucose level. Complete an incident report. Reprimand the UAP for the incorrect blood glucose. Report the incident to the healthcare provider.

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

The nurse is caring for a client following a motor vehicle accident resulting in paraplegia. While the client is being prepared for discharge to home, the client's spouse expresses concern about the ability to carry the client, asking "What if I injure my back or drop them?" What discharge teaching should the nurse emphasize related to this concern? the importance of monitoring urinary elimination nutritional changes for the client with paraplegia ergonomic principles and body mechanics signs and symptoms of chronic back pain that should be reported to a health care provider

ergonomic principles and body mechanics Explanation: The spouse's question indicates a need for teaching regarding safe client mobility and transfer techniques. Although urinary elimination and nutrition are components of care for clients with paraplegia, education about ergonomic principles and body mechanics is most appropriate at this time based on the spouse's statement. The goal is to provide the spouse with skills to prevent self-injury, not to help identify it.

The nurse understands that the client who is undergoing induction therapy for leukemia needs additional instruction when the client makes which statement? "I will have to pace my activities with rest periods." "I must report a temperature of 100° F (37.7 C)." "I cannot wait to get home to my cat!" "I will use warm saline gargle instead of brushing my teeth."

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

A client diagnosed with depression threatens suicide and is placed on constant observation. When the client asks to use the toilet, the nurse follows the client into the bathroom. The client says, "I don't need you to follow me into the bathroom. Give me some space." Which statement by the nurse would be considered the most appropriate? "There is nothing dangerous in the bathroom. I will wait for you in the hallway." "If you think you are going to be alright, I will check on you in 5 minutes." "You're right. I don't need to come into the bathroom. I will wait outside." "I must stay with you until we are sure you are not going to hurt yourself."

"I must stay with you until we are sure you are not going to hurt yourself." Explanation: The client has expressed suicidal thoughts and has been placed on constant supervision. Staying with the client, even when the client is in the bathroom, demonstrates an understanding of constant observation. Staying with the client also demonstrates professional judgment regarding the situation. The other options do not ensure the client's safety during this time of crisis.

A client is to have a below-the-knee amputation. Prior to the surgery, what should the circulating nurse in the operating room do? Verify that the surgeon possesses the degree of expertise needed. Insert a Foley catheter. Start an intravenous infusion. Initiate a time-out.

Initiate a time-out. Explanation: The Universal Protocol is used to prevent wrong site, wrong procedure, and wrong person surgery. Actions included in the protocol are as follows: conduct a preprocedural verification process, mark the procedure site, and perform a time out. Exceptions to the Universal Protocol are routine or "minor" procedures, such as venipuncture, peripheral IV line placement, insertion of oral/nasal drainage or feeding tubes, or Foley catheter insertion. Prior to closure, the surgeon or circulating nurse will initiate a time out to verbally confirm a review of informed consent and procedures completed; all specimens are identified, accounted for, and accurately labeled; and all foreign bodies have been removed. The Chief of Surgery and Medical Director are the ones who will verify the surgeons' levels of expertise.

Bacterial conjunctivitis has affected several children at a local day care center. A nurse should advise which measure to minimize the risk of infection?

Perform thorough hand washing before and after touching any child in the day care center. Explanation: Bacterial conjunctivitis is very contagious. Attention should be paid to thorough hand washing, a major means of stopping the transmission of the disease. Closing the day care center for 1 week is not necessary because thorough hand washing will stop the spread of the infection. Keeping the children out for 48 hours is not necessary. A child may return to day care after being treated for 24 hours. Although the parents of each child should be told about the outbreak, doing so will not help to curtail or prevent the spread of the infection.

Before assisting a client to ambulate after surgery, the nurse helps the client to dangle the feet over the side of the bed. Which action will best prepare the client to dangle the feet over the side of the bed? Position the client on his or her side for 5 minutes. Place the client in a high Fowler's position. Administer a prescribed analgesic 10 minutes prior to getting out of bed. Have the client flex and extend the feet while in a recumbent position.

Place the client in a high Fowler's position. Explanation: Many clients feel faint and weak when helped to ambulate for the first time after surgery. The client's circulatory system needs time to adjust to an upright position before the client is helped to a standing position. This is best done by placing the client in high Fowler's position in bed for a few minutes. After becoming accustomed to a sitting position, the client can then be helped to dangle the feet at the edge of the bed before ambulating.Although analgesics can promote comfort for the postoperative client, some can sedate the client and should not be given at the time the client is assisted out of bed.Having the client lie on the side of the bed or do leg exercises will not prepare the client to dangle the legs.

The nurse is planning to move a box of dialysis solution in a client's room. Which action should the nurse take to reduce the risk of a back injury? Stand close to the box. Face away from the direction of movement. Use the arms to push the box into position. Twist the body to move the box.

Stand close to the box Explanation: The nurse should work as closely as possible to the object that needs to be lifted or moved. This closeness brings the body's center of gravity close to the object being moved, permitting most of the burden to be on the leg and arm muscles and not the back muscles. Twisting should be avoided because this strains back muscles. The weight of the body, and not the arms, should be used to push the object. This reduces the amount of strain on the arms and back. The direction of the move should be faced when moving an object.

A client with recurrent, endogenous depression has been hospitalized on the psychiatric unit for 3 days. He exhibits psychomotor retardation, anhedonia, indecision, and suicidal thoughts. Which goal of nursing care should have highest priority? Provide for contact between the client and his wife. Maintain a calm environment. Reassure the client of his worthiness. Use measures to protect the client from harming himself.

Use measures to protect the client from harming himself. Explanation: Whenever a client is suicidal, steps must be taken to prevent the client from self-harm. Other goals of care are less important than being sure the client does not carry out the threat of suicide. All suicide threats should be taken seriously, and proper precautions should be taken to protect the client from self-harm. Providing for contact between the client and his wife is not the highest priority, may not be therapeutic, and would require the client's consent. Reassuring the client of his worthiness is not as high a priority as is his safety. Furthermore, reassurance is not helpful because logical explanation will not change the client's negative thinking. Interventions designed to increase the client's self-esteem are important but are not the highest priority. Maintaining a calm environment is helpful but is not a priority.

The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse observes which action? wearing of sterile gloves to bathe a neonate at 2 hours of age disposal of used scalpel blades in a puncture-resistant container use of protective goggles during a caesarean birth placement of bloody sheets in a container designated for contaminated linens

wearing of sterile gloves to bathe a neonate at 2 hours of age Explanation: One of the staff members needs further instructions when the nurse observes the staff member wearing sterile gloves to bathe a neonate at 2 hours of age. Clean gloves should be worn, not sterile gloves. Sterile gloves are more expensive than clean gloves and are not necessary when bathing a neonate. Wearing protective goggles during a cesarean birth is a standard blood precaution. Bloody sheets should be placed in a designated container. Scalpel blades, needles, syringes, and other equipment used during birthing should be disposed of safely in appropriate, labeled containers.

A 31-year-old client, G3, T0, P2, Ab0, L0 at 32 weeks' gestation, is being admitted to the hospital with contractions of moderate intensity occurring every 3 to 4 minutes per the client report. The client is crying on admission; the history reveals that the client has previously had two nonviable fetuses at 30 weeks' gestation. What nursing action would be the highest priority for this client? Prepare for immediate administration of magnesium sulfate. Assess maternal contraction and fetal heart rate pattern. Review history of prior fetal demises with client. Reassure the client that this baby will be healthy.

Assess maternal contraction and fetal heart rate pattern. Explanation: The physical aspects of care have a higher priority than the psychosocial aspects. The client report is part of the electronic medical record, but the maternal contraction pattern and the fetal heart rate pattern must be completed immediately upon admission to establish a baseline. The need for a tocolytic agent cannot be determined until the maternal fetal unit has been assessed. Assessment of the circumstances and etiologies of the prior fetal demises are important but are not of the highest importance. The psychosocial aspects are very important in the care of this client and can briefly be discussed as the physical aspects of assessment are being completed, but in-depth psychosocial care will need to wait until the physical aspects have been completed.

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 client in private room with clear signage about allergy. Avoid using oil-based lotions on the client's skin. Ensure client's roommate does not have an indwelling latex urinary catheter. Place latex-free, powder-free gloves at client's bedside.

Place latex-free, powder-free gloves at client's bedside. Explanation: Latex-free, powder-free gloves reduce the risk of respiratory exposure to latex. Having them conveniently located will enhance staff adherence, so this is the most important intervention. Using oil-based hand lotion should be avoided when wearing latex gloves because this increases risk of latex breakdown and can increase latex exposure for the person wearing the gloves. However, the client can have oil-based lotions applied to the skin as this is not contraindicated. Obviously, the nurse would wear latex-free gloves for application, or no gloves at all if no contact with body fluids is expected. Having a roommate with a latex catheter does not pose a risk of direct exposure for the client. Clients wit

Entering a client's room, a nurse on the maternity unit sees a mother slapping the face of a crying neonate. Which action should the nurse take in this situation? Return the neonate to the nursery, inform the physician so the physician can thoroughly examine the neonate for injuries, and notify social services for assistance. Confront the mother by asking her what she's doing and why. Return the neonate to the nursery and inform coworkers so they can monitor the mother's behavior. Leave the room immediately, without the neonate, and notify the nursing supervisor.

Return the neonate to the nursery, inform the physician so the physician can thoroughly examine the neonate for injuries, and notify social services for assistance. Explanation: The neonate's safety and protection is the first priority. The nurse should immediately return the neonate to the nursery and inform the physician of the neonate's abuse. By being the neonate's advocate, the nurse allows the physician to examine the neonate for injuries resulting from the incident. Social services should be notified. The neonate shouldn't remain in the room with the mother unsupervised. The nurse should follow the facility's policy and procedure for reporting suspected and actual child abuse. Although the incident may be part of the mother and neonate's revised care plan, it requires immediate intervention, not simple notification of coworkers. Confronting the mother doesn't provide for the neonate's safety.

The nurse received an order to administer intravenous fluids with potassium for a client receiving intravenous fluids. What step(s) are included in the process? Select all that apply. Obtain correct ordered intravenous fluids. Assist the client with ambulation. Review the label of the intravenous tubing. Review the client's laboratory values. Identify client with two methods.

Review the client's laboratory values. Obtain correct ordered intravenous fluids. Identify client with two methods. Review the label of the intravenous tubing. Explanation: The nurse will review the client's laboratory values, obtain correct ordered intravenous fluids, and identify client with two methods. The intravenous tubing should already have been labeled from the previous fluids so the nurse should review the label. Assisting the client with ambulation is not part of the intravenous fluid procedure.

The night nurse has completed the change of shift report. As the day nurse makes rounds on a postpartum client receiving magnesium sulfate, it is noted the client developed significantly elevated blood pressure during the past shift. Further assessment reveals the magnesium sulfate rate is infusing well below the prescribed rate. In addition to adjusting the infusion rate and notifying the health care provider (HCP), what is the most important action by the nurse? Complete an incident report. Ask the charge nurse if an incident report is necessary. Discuss the matter with the night nurse the next time she works. Evaluate the client's BP for 4 hours before making decision.

Complete an incident report. Explanation: Safety is the highest priority, and a nursing error has occurred. If the day nurse decides to tell the night nurse, the timing of the notification will be up to the nurse initiating the incident report. The nurse should confer with the charge nurse concerning the incident, but completion of the report is required. Waiting for several hours to initiate the report based on changes in client data and assessment is not an ethical or professional decision and should not be considered; again, safety is the highest priority.

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? Remind them that they are lucky to be alive. Encourage them to verbalize their feelings. Encourage them to contact family members Remind them that everyone is doing the best they can.

Encourage them to verbalize their feelings. Explanation: The most appropriate action by the nurse is to encourage the individuals to verbalize their feelings. Once the nurse has allowed the person to verbalize their feelings, it may be appropriate to ensure the individual has additional supportive people with whom to talk such as family members. Reminding the person that everyone is doing their best closes off therapeutic conversations between the individual and the nurse. Telling survivors that they should be grateful that they are alive also closes off therapeutic communication.

An obese client has returned to the unit after receiving electroconvulsive therapy (ECT). A nurse requests assistance in moving the client from the stretcher to the bed. Which direction should the nurse give to a nurse who volunteers to help? "Obtain the sliding board or two other people to assist us." "Get the hydraulic lift; the client is still groggy." "Place the client on the side then use a drawsheet to bring the client to the bed." "Place the client in a semi-Fowler's position to make the move easier."

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

What is the nurse's most important intervention for a client having a tonic-clonic seizure? Note the origin of seizure activity Protect the client from further injury Insert a padded tongue blade to prevent the client from biting his tongue Time the duration of the seizure

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

A diagnosis of hemophilia A is confirmed in an infant. Which of the instructions should the nurse provide the parents as the infant becomes more mobile and starts to crawl? Check the color of the child's urine every day. Sew thick padding into the elbows and knees of the child's clothing. Expect the eruption of the primary teeth to produce moderate to severe bleeding. Administer one-half of a children's aspirin for a temperature higher than 101° F (38.3° C).

Sew thick padding into the elbows and knees of the child's clothing. Explanation: As the hemophilic infant begins to acquire motor skills, falls and bumps increase that risk of bleeding. Such injuries can be minimized by padding vulnerable joints. Aspirin is contraindicated because of its antiplatelet properties, which increase the infant's risk for bleeding. Because genitourinary bleeding is not a typical problem in children with hemophilia, urine testing is not indicated. Although some bleeding may occur with tooth eruption, it does not normally cause moderate to severe bleeding episodes in children with hemophilia.

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." "In the future, have the physician write an order for PPE for clients with colostomies." "You should be aware that PPE is used when caring for any client in the hospital." "If you're not using PPE, you need to be careful not to touch any of the drainage."

"PPE should be used when you risk exposure to blood or bodily fluids." Explanation: Personal protective equipment or a barrier should be used when there is a risk that blood or other bodily fluids may come in contact with the nurse's skin or mucous membranes. This is a decision that can be independently made by the nurse and can be used when the nurse deems it appropriate. It is not necessary to use personal protective equipment or a barrier in every client contact. It is a nursing decision and does not need a physician's order.

A client recovering from a stroke has slid down in bed and needs to be repositioned. Which action should the nurse take to ensure safety for both the client and the nurse? Roll the client side to side. Ask for assistance from the lift team. Stand at the head of the bed and slide the client toward the pillow. Raise the head of the bed before repositioning.

Ask for assistance from the lift team. Explanation: A safe and effective approach to client repositioning is the use of a lift team. When using a team, a group of care providers share the weight of the client, reducing the risk of personal injury, and providing a safe method of repositioning the client. Rolling the client side to side is not a correct action to reposition a client in bed. The bed should be flat when repositioning a client. Raising the head of the bed will cause the client to slide further down in the bed. Any attempts at repositioning will be difficult because of the client's angle in the bed. Standing at the head of the bed and sliding the client toward the pillow is also not an appropriate method to reposition a client in bed.

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

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

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

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

An infection control nurse is reviewing the care of a client diagnosed with Clostridium difficile infection. The nurse determines that the staff is adhering to appropriate infection control precautions based on implementation of which measure? contact precautions droplet precautions airborne precautions protective precautions

contact precautions Explanation: For a client with Clostridium difficile infection, it is imperative to institute contact precautions for the duration of the illness when providing care to the client to minimize the risk of disease transmission. Airborne precautions would be used for a client with an infection, such as tuberculosis, that is transmitted by small droplets that can remain suspended and widely dispersed by air currents. Droplet precautions would be used for a client with an infection, such as diphtheria or rubella, that is transmitted by large-particle droplets that are dispersed into air currents. Protective precautions would be used for a client with compromised immunity as evidenced by a significantly reduced neutrophil count, such as from chemotherapy or immunosuppressive agents.

One evening, the client takes the nurse aside and whispers, "Don't tell anybody, but I'm going to call in a bomb threat to this hospital tonight." Which action is the priority? warning the client that his telephone privileges will be taken away if he abuses them offering to disregard the client's plan if he does not go through with it notifying the proper authorities after saying nothing until the client has actually completed the call explaining to the client that this information will have to be shared immediately with the staff and the health care provider (HCP)

explaining to the client that this information will have to be shared immediately with the staff and the health care provider (HCP) Explanation: The priority is to explain to the client that this information has to be shared immediately with the staff and the HCP because of its serious nature. Safety of all is crucial regardless of whether the client follows through on his plan. It is possible that the client is asking to be stopped and that he is indirectly pleading for help in a dysfunctional manner. Bargaining with the client, such as warning him that his telephone privileges will be taken away if he abuses them, or offering to disregard his plan if he does not go through with it, is inappropriate. Saying nothing to anyone until the client has actually completed the call and then notifying the proper authorities represent serious negligence on the part of the nurse.

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 nausea hypoventilation psoriasis

pruritus Explanation: The nurse should be alert for pruritus, which may indicate a mild anaphylactic reaction to the arteriogram dye. The client would have an increased respiratory rate. Nausea would be more likely with a food allergy or intolerance and would not be associated with a reaction to the dye. Psoriasis is a chronic condition triggered by a hyperimmune response.