Safety

A boy, age 3, develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a baby girl. Which statement by the mother best indicates that she understands the implications of rubella? "I told my husband to give my son aspirin for his fever." "I'll ask the physician about giving the baby an immunization shot." "I don't have to worry because I've had the measles." "I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my son."

"I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my son." By saying she'll call her pregnant neighbor, the mother demonstrates that she understands the implications of rubella. Fetal defects can occur during the first trimester of pregnancy if the pregnant woman contracts rubella. Aspirin shouldn't be given to young children because aspirin has been implicated in the development of Reye's syndrome. Acetaminophen should be used instead of aspirin. Rubella immunization isn't recommended for children until ages 12 to 15 months. Having the measles (rubeola) won't provide immunity for rubella.

A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when the client says: "My tuberculosis isn't contagious after I take the medication for 24 hours." "I'm clear when my chest X-ray is negative after one month of medication." "I'm contagious as long as I have night sweats." "I'll stop being contagious when I have a negative acid-fast bacilli test."

"I'll stop being contagious when I have a negative acid-fast bacilli test."

The nurse observes a family member of a client who is on contact precautions enter and exit the client's room without performing hand hygiene. What is the nurse's most appropriate action? Offer to show family members how to perform hand hygiene using soap and water or alcohol rub. Document the family member's action, and explain the phenomenon of hospital-acquired infections. Inform the family members that they must comply with the client's contact precautions. Document the family member's action, and move the signage on the client's door to a more conspicuous location.

Correct response: Offer to show family members how to perform hand hygiene using soap and water or alcohol rub. Explanation: The nurse should address the family member's oversight and promote infection control, but in a way that is nonconfrontational. Offering to show the family members how to perform hand hygiene achieves these goals. Moving signage may not result in a behavior change. Speaking about hospital-acquired infections may not result in improved hand hygiene.

A nurse implements a health care facility's disaster plan. Which action should she perform first? - Turn off all cellular phones and pagers. -Instruct all essential off-duty personnel to report to the facility within 24 hours. -Identify a command center at which activities are coordinated. -Provide treatment for incoming clients according to time of admission.

Identify a command center at which activities are coordinated. 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.

A nurse is caring for a client with a history of falls. The nurse's first priority when caring for a client at risk for falls is: placing the call light on the bedside table. keeping the bed in the lowest possible position. instructing the client not to get out of bed without assistance. keeping the bedpan available so that the client doesn't have to get out of bed.

Keeping the bed at the lowest possible position is the first priority for clients at risk for falling. The call light should be placed so that it is easily accessible. Instructing the client not to get out of bed may not effectively prevent falls — for example, if the client is confused.

A nurse is preparing a client for cardiac catheterization. What is the nurse's priority assessment? Weight and height Known allergies Apical heart rate Cardiac rhythm

Known allergies Since cardiac catheterization involves the injection of a radiopaque dye. It is most important for the nurse to determine if this client has allergies to iodine or shellfish. The other three parameters are also part of the assessment, but are not the priority.

A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad? Client's risk for falls Client's vital signs and breath sounds Client's nutritional status ' Client's level of consciousness

LOC A client who has impaired consciousness or altered mental status is at increased risk for injury from a heating pad.

A nurse is teaching parents about accident prevention for a toddler. Which guideline is most appropriate? Always make the toddler wear a seat belt when riding in a car. Make sure all medications are kept in containers with childproof safety caps. Never leave a toddler unattended on a bed. Teach rules of the road for bicycle safety.

Make sure all medications are kept in containers with childproof safety caps. Making sure all medications are kept in containers with childproof safety caps is the most appropriate guideline because poisoning accidents are common in toddlers owing to the toddler's curiosity and his increasing mobility and ability to climb. When riding in a car, a toddler should be strapped into a car seat, not a seat belt.

A nursing assistant escorts a client in the early stages of labor to the bathroom. When the nurse enters the client's room, she detects a strange odor coming from the bathroom and suspects the client has been smoking marijuana. What should the nurse do next? Tell the client that smoking is prohibited in the facility, and that if she smokes again, she'll be discharged. Explain to the client that smoking poses a danger of explosion because oxygen tanks are stored close by. Notify the physician and security immediately. Ask the nursing assistant to dispose of the marijuana so that the client can't smoke anymore.

Notify the physician and security immediately.

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? Administer a prescribed analgesic 10 minutes prior to getting out of bed. Position the client on his or her side for 5 minutes. Have the client flex and extend the feet while in a recumbent position. Place the client in a high Fowler's position.

Place the client in a high Fowler's position.

A nurse realizes that data has been entered on the wrong client's written health record. Which of the following steps should the nurse take to correct this documentation error? Use liquid paper to cover over the incorrect entry. Use a black marker to cross over the incorrect entry. Put a line through the entry, leaving the content visible, and initialize. Tear out the page, and recopy the other entries on the page.

Put a line through the entry, leaving the content visible, and initialize. The nurse should put a line through the incorrect entry, leaving the original entry visible, and then sign the entry. The other options are incorrect and do not follow nursing documentation standards.

A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then:

The nurse should instruct the client to advance both crutches to the step below, then transfer his body weight to the crutches as he brings the affected leg to the step. The client should then bring the unaffected leg down to the step. advance both crutches.

A nurse should question an order for a heating pad for a client who has: active bleeding. a reddened abscess. an edematous lower leg. purulent wound drainage.

active bleeding.

The client has returned to the surgery unit from the postanesthesia care unit (PACU). The client's respirations are rapid and shallow, the pulse is 120 bpm, and the blood pressure is 88/52 mm Hg. The client's level of consciousness is declining. The nurse should first: call the PACU. call the health care provider (HCP). call the respiratory therapist. call the rapid response team (RRT)/medical emergency team.

call the rapid response team (RRT)/medical emergency team.

Automated external defibrillators (AEDs) are used in cardiac arrest situations for: early defibrillation in cases of atrial fibrillation. cardioversion in cases of atrial fibrillation. pacemaker placement. early defibrillation in cases of ventricular fibrillation.

early defibrillation in cases of ventricular fibrillation. AEDs are used for early defibrillation in cases of ventricular fibrillation.

A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, the nurse should first? institute droplet precautions. obtain the child's vital signs. ask the parent about medication allergies. inquire about the health of siblings at home.

institute droplet precautions.

A nurse is instructing a school-age child with a fracture on proper use of crutches. Which statement made by the nurse is most accurate? "After advancing both crutches the length of one step, move your 'good' leg forward." "After advancing both crutches the length of one step, move your 'bad' leg forward." "Move one crutch forward, then advance your 'good' leg." "Move one crutch forward, then advance your 'bad' leg."

"After advancing both crutches the length of one step, move your 'bad' leg forward." When walking with crutches, a child should be instructed to advance both crutches, then advance the affected leg. The unaffected leg then supports much of the weight associated with ambulation. It wouldn't be effective to move the unaffected leg forward first. It wouldn't be safe for the child to advance only one crutch.

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? - 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. - Tell staff members to use whatever procedures they feel are best.

Determine that the procedures currently in place must be followed and direct staff to follow them without question.

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? 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. Check the color of the child's urine every day. Expect the eruption of the primary teeth to produce moderate to severe bleeding.

Sew thick padding into the elbows and knees of the child's clothing.

A client with toxoplasmosis and cytomegalovirus is confused and has been dislodging his I.V. access device. He's scheduled to receive amphotericin B I.V. Which action would be most appropriate for the nurse to take? Place bilateral wrist restraints on the client. Ask the physician to order sedation for the client. Delay giving the drug until the client's confusion disappears. Tell a nursing assistant to stay with the client during the infusion.

Tell a nursing assistant to stay with the client during the infusion. The client needs the medication to combat the protozoal infection. Because he has been dislodging the I.V. access devices, a staff member should remain with him during the infusion. Bilateral wrist restraints are a poor choice for managing this situation, and using them doesn't ensure that the client will receive the medication. Giving sedation to a confused client is risky, and it's a poor alternative to having a staff member remain with the client. Administering the drug shouldn't be delayed; appropriate nursing action allows for the drug's administration.

After his spouse has visited, a client begins crying and saying that his spouse is a mean person. When the client starts pounding on the overbed table and using incomprehensible language, the nurse feels she can't handle the situation. What should the nurse do at this time? Tell the client that his spouse is probably under a lot of stress. Instruct the client to stop pounding on the overbed table. Call facility security to control the situation. Use the call system to request assistance.

Use the call system to request assistance. A nurse who feels she can't handle a problem should use the call system to seek assistance. The nurse should stay with the client until help arrives, unless the nurse feels that personal harm is imminent. Telling the client his spouse is under stress and instructing the client not to pound the table are inappropriate because they're nontherapeutic responses; they don't address the client's feelings or needs. Informing facility security is an overreaction to the situation at this point.

A client has a coxackie B (viral) or trypanosomal (parasite) infection. The nurse should further assess the client for: myocarditis. myocardial infarction. renal failure. liver failure.

myocarditis. 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.

The client with tuberculosis is to be discharged home with nursing follow-up. Which aspect of nursing care will have the highest priority? offering the client emotional support teaching the client about the disease and its treatment coordinating various agency services assessing the client's environment for sanitation

teaching the client about the disease and its treatment Ensuring that the client is well educated about tuberculosis is the highest priority. Education of the client and family is essential to help the client understand the need for completing the prescribed drug therapy to cure the disease. O