Safety/Infection Control - Saunders Quiz 3
Treatment for a client with bleeding esophageal varices has been unsuccessful and the health care provider decides to insert a Sengstaken-Blakemore tube. What is the priority nursing action? 1. Request an obturator. 2. Obtain a Kelly clamp. 3. Place a pair of scissors at client's bedside. 4.Pour sterile water in the irrigation set basins.
3. Place a pair of scissors at client's bedside.
The nurse is preparing to instill medication into a client's nasogastric tube. Which actions should the nurse take before instilling the medication? Select all that apply. 1. Check the residual volume. 2. Aspirate the stomach contents. 3. Turn off the suction to the nasogastric tube. 4. Remove the tube and place it in the other nostril. 5. Check the stomach contents for a pH of less than 3.5.
1. Check the residual volume. 2. Aspirate the stomach contents. 3. Turn off the suction to the nasogastric tube. 5. Check the stomach contents for a pH of less than 3.5.
The nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse should next assess which item? 1. Client's temperature 2. Expiration date on the bag 3. Time of last dressing change 4. Tightness of tubing connections
1. Client's temperature
A client is being discharged to home after application of a plaster leg cast. Which statement indicates to the nurse that the teaching has been effective? 1. "I will avoid getting the cast wet." 2. "I will use my fingertips to lift and move the leg." 3. "I can use a padded coat hanger end to scratch under the cast." 4. "I need to cover the casted leg with warm blankets for the next few days."
1. "I will avoid getting the cast wet."
The nurse is preparing to discontinue a client's nasogastric (NG) tube. The client is positioned properly and the tube has been flushed with 15 mL of air to clear secretions. Which statement should the nurse make to the client before removing the tube? 1. "Take a deep breath when I tell you, and hold it while I remove the tube." 2. "Take a deep breath when I tell you, and bear down while I remove the tube." 3. "Take a deep breath when I tell you, and slowly exhale while I remove the tube." 4. "Take a deep breath when I tell you, and breathe normally while I remove the tube."
1. "Take a deep breath when I tell you, and hold it while I remove the tube."
A nurse is caring for a client who is scheduled for abdominal surgery and administers the preoperative medications as prescribed. The nurse then raises the side rails on the stretcher, places the safety strap across the client, places the call bell near the client, and instructs the client to call for assistance as needed. Shortly thereafter the client calls the nurse and reports the need to urinate. Which action should the nurse take to meet this client's need? 1. Assist the client onto a bedpan. 2. Assist the client to the bathroom. 3. Contact the health care provider and request a prescription for a Foley catheter. 4. Tell the client that preoperative medications cause the urge to void, and check the bladder for distention.
1. Assist the client onto a bedpan.
The ambulatory care nurse is working with a 22-year-old female client who has been diagnosed with pelvic inflammatory disease (PID). The nurse incorporates which item in a teaching plan for this client? 1. Avoid frequent douching. 2. Undergarments made of nylon are best. 3. Intrauterine devices are a good birth control method. 4. It is necessary to change sanitary pads only every 8 hours.
1. Avoid frequent douching.
The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse prepares to attach the distal end of the IV tubing to a needleless device, the tubing drops and hits the top of the medication cart. Which is the appropriate action by the nurse? 1. Change the IV tubing. 2. Attach a new needleless device. 3. Wipe the tubing port with Betadine. 4. Scrub the needleless device with an alcohol swab.
1. Change the IV tubing.
A client with active tuberculosis demonstrates less-than-expected interest in learning about the prescribed medication therapy. The nurse assesses that this client may ultimately need which intervention as a last resort? 1. Directly observed therapy 2. More medication instructions 3. Involvement of the family in teaching 4. Reinforcement by the health care provider
1. Directly observed therapy
A nurse is preparing an intravenous (IV) set before starting the infusion. After removing the cap from the IV tubing port on the IV bag, the nurse removes the cover from the tubing insertion spike, but then touches the spike with a finger. What should the nurse do next? 1. Discard the IV tubing and use a new set for the infusion. 2. Continue on with the procedure and then flush the tubing thoroughly. 3. Clean the spike with an alcohol swab for 15 seconds and then continue. 4. Clean the spike and the IV bag tubing port with alcohol and then continue.
1. Discard the IV tubing and use a new set for the infusion.
A client is in extreme pain from scrotal swelling that is caused by epididymitis. The nurse administers an intramuscular opioid analgesic in the left arm to relieve the pain. The nurse should plan to take which action next? 1. Ensure client safety. 2. Dim the lights in the room. 3. Check the name bracelet of the client. 4. Perform range-of-motion exercises to the left arm to promote medication absorption.
1. Ensure client safety.
A nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. How often should the nurse plan to check the IV infusions and IV sites of these clients? 1. Every 1 hour 2. Every 2 hours 3. Every 3 hours 4. Every 4 hours
1. Every 1 hour
The nurse checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take? 1. Hold the feeding. 2. Reinstill the amount and continue with administering the feeding. 3. Elevate the client's head at least 45 degrees and administer the feeding. 4. Discard the residual amount and proceed with administering the feeding.
1. Hold the feeding.
The nurse in the health care clinic is preparing to obtain a throat swab for culture in a client suspected of having a beta-hemolytic streptococcal infection. Which actions are appropriate in collecting this specimen? Select all that apply 1. Instruct the client to tilt the head back. 2. Swab the tonsillar pillars and the posterior pharynx wall. 3. Tell the client that the test will help identify microorganisms. 4. Ask the client to open the mouth; then swab the back of the tongue. 5. Place a tongue depressor on the client's tongue before swabbing the throat.
1. Instruct the client to tilt the head back. 2. Swab the tonsillar pillars and the posterior pharynx wall. 3. Tell the client that the test will help identify microorganisms. 5. Place a tongue depressor on the client's tongue before swabbing the throat.
A female client seen in the ambulatory care clinic has a history of syphilis infection. The nurse assessing the client for reinfection would expect to observe a lesion on the labia that has which characteristic? 1. Is painless and indurated 2. Has a cauliflower-like appearance 3. Is erythematous and papular in appearance 4. Appears as one or more vesicles that then rupture
1. Is painless and indurated
The nurse is teaching a client with acquired immunodeficiency syndrome (AIDS) how to avoid food-borne illnesses. The nurse should instruct the client that which food can cause a food-borne illness? 1. Raw oysters 2. Bottled water 3. Pasteurized milk 4. Products with sorbitol
1. Raw oysters
The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next? 1. Reassess the client. 2. Conduct a staff meeting to describe the fall. 3. Document in the nurse's notes that an incident report was completed. 4. Contact the nursing supervisor to update information regarding the fall.
1. Reassess the client.
The community health nurse has instructed a group of parents of preschoolers about home safety measures for children. Which statement by one of the parents should the nurse identify as something that requires the need for reinforcement of the instructions? 1. Refers to medication as "candy for when you are sick" 2. Says he or she will store medications in child-proof containers 3. Keeps the Poison Control Center telephone number readily available 4. States the intention to label all toxic substances and place them in a locked area
1. Refers to medication as "candy for when you are sick"
A registered nurse (RN) asks a licensed practical nurse (LPN) to set up a hospital room for a client who is being admitted with a diagnosis of tonic-clonic seizures and asks the LPN to institute seizure precautions. The RN checks the client's room before the arrival of the client and determines that which item placed in the room by the LPN is unsafe? 1. Restraints 2. Nasal cannula 3. Suction catheter 4. Padding for side rails
1. Restraints
A nurse is developing a plan of care for a client with late-stage Alzheimer's disease. The nurse identifies which client problem as having the highest priority? 1. Risk for injury 2. Social isolation behaviors 3. Role performance alterations 4. Inability to communicate verbally
1. Risk for injury
A health care provider has written a prescription for wrist restraints to be applied on a client from 10:00 PM to 7:00 AM because the client becomes disoriented during the night and is at risk for pulling out the nasogastric tube and the intravenous catheter. At 11:00 PM, the charge nurse makes rounds on all of the clients in the unit. When assessing the client with the restraints, which observation by the charge nurse indicates that the nurse who applied the restraints performed an unsafe action? 1. The restraints were applied tightly. 2. A safety knot was used to secure the restraints. 3. The call light was placed within reach of the client. 4. The client's record indicates that the restraints will be released every 2 hours.
1. The restraints were applied tightly.
The nurse provides home care instructions to a client with hepatitis B. Which statement made by the client indicates the best understanding of how to prevent transmission of the disease? 1. "It is all right to kiss my wife." 2. "My wife should get the vaccine." 3. "I should be vaccinated as soon as possible." 4. "I never will share towels with anyone else."
2. "My wife should get the vaccine."
The nurse is assessing the intravenous (IV) dressing of a client with a peripheral IV infusion running. The date on the dressing is 7/25 (July 25). The nurse documents on the client's record that the dressing should be changed on which date? 1. 7/26 2. 7/28 3. 7/30 4. 8/1
2. 7/28
A client is seen in the health care clinic, and a diagnosis of acute sinusitis is made. The nurse provides home care instructions to the client regarding measures that will promote sinus drainage and comfort. Which statement by the client indicates a need for further instruction? 1. "I should drink large amounts of fluids." 2. "I should use a hot mist vaporizer to liquefy secretions." 3. "I should try to sleep with the head of the bed elevated." 4. "I should apply heat, such as a wet pack, over the sinuses."
2. "I should use a hot mist vaporizer to liquefy secretions."
The nurse is preparing to administer an intramuscular (IM) injection to a client receiving a continuous heparin infusion. Which action should the nurse prepare to do? 1. Use a ⅝-inch needle for the injection. 2. Apply prolonged pressure to the IM site after the injection. 3. Apply a 4 × 4 pressure dressing at the IM site after the injection. 4. Decrease the rate of the heparin infusion for 1 hour before and 1 hour after the injection.
2. Apply prolonged pressure to the IM site after the injection.
The nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the nurse inflates the balloon, the client complains of discomfort. The nurse should take which appropriate action? 1. Aspirate the fluid, remove the catheter, and insert a new catheter. 2. Aspirate the fluid, advance the catheter farther, and reinflate the balloon. 3. Remove the syringe from the balloon; discomfort is normal and temporary. 4. Aspirate the fluid, withdraw the catheter slightly, and reinflate the balloon.
2. Aspirate the fluid, advance the catheter farther, and reinflate the balloon.
The nurse is caring for a client with acute viral hepatitis A who resides in a group home. Which outcome indicates that the most important goal has been achieved for this client? 1. Resumes normal bowel elimination patterns 2. Avoids transmitting the virus to others in the group home 3. Progressively increases activity with planned rest periods 4. Gains at least ½ to 1 pound per week until at ideal weight
2. Avoids transmitting the virus to others in the group home
The client seen in the health care clinic has tested positive for gonorrhea. The nurse anticipates that which medication will be prescribed based on this finding? 1. Acyclovir (Zovirax) 2. Ceftriaxone (Rocephin) 3. Azithromycin (Zithromax) 4. Penicillin G benzathine (Bicillin LA)
2. Ceftriaxone (Rocephin)
The nurse is preparing to initiate an intravenous line containing a high dose of potassium chloride and plans to use an intravenous infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action? 1. Initiate the intravenous line without the use of a pump. 2. Contact the electrical maintenance department for assistance. 3. Plug in the pump cord in the available plug above the room sink. 4. Use an extension cord from the nurses' lounge for the pump plug.
2. Contact the electrical maintenance department for assistance.
The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first? 1. Check for medication interactions. 2. Determine whether there are medication duplications. 3. Call the prescribing health care provider (HCP) and report polypharmacy. 4. Determine whether a family member supervises medication administration.
2. Determine whether there are medication duplications.
The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse develops a postoperative plan of care for the client and should include which intervention in the plan? 1. Maintain the client in a prone position. 2. Elevate and immobilize the grafted extremity. 3. Maintain the grafted extremity in a flat position. 4. Keep the grafted extremity covered with a blanket.
2. Elevate and immobilize the grafted extremity.
The nurse has admitted a client to the clinical nursing unit following a right-sided mastectomy. The nurse should plan to place the right-sided arm in which position? 1. Elevated above shoulder level 2. Elevated on one or two pillows 3. Level with the right-sided atrium 4. Dependent to the right-sided atrium
2. Elevated on one or two pillows
The nurse is instructing a client who had a stroke and has weakness on one side how to ambulate with the use of a cane. Which instruction should the nurse provide to the client? 1. Hold the cane on the affected (weak) side. 2. Hold the cane on the unaffected (strong) side. 3. Move the cane forward first along with the unaffected (strong) leg. 4. Move the cane and the unaffected (strong) leg down first when going down stairs.
2. Hold the cane on the unaffected (strong) side.
The nurse is preparing the morning medications to be administered to her assigned clients and is reviewing the health care provider's prescriptions. Which medication prescription should the nurse question? 1. Lanoxin (Digoxin) 0.25 mg orally daily 2. Hydrochlorothiazide (HCTZ) orally twice daily 3. Docusate sodium (Colace) 100 mg orally twice daily 4. Enoxaparin sodium (Lovenox) 20 mg subcutaneously daily
2. Hydrochlorothiazide (HCTZ) orally twice daily
The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. What action should the nurse take next? 1. Immediately inflate the balloon. 2. Insert the catheter 2.5 cm to 5 cm and inflate the balloon. 3. Withdraw the catheter about 1 inch and inflate the balloon. 4. Insert the catheter until resistance is met and inflate the balloon.
2. Insert the catheter 2.5 cm to 5 cm and inflate the balloon.
The nurse is preparing to apply a mitten restraint to the client's hand. The nurse should take which action to ensure that the restraint is applied correctly? 1. Applies the restraint loosely 2. Makes sure that two fingers can be inserted under the restraint 3. Secures the restraint straps to the side rail using a quick-release tie 4. Makes sure that the sheepskin is on the outside rather than against the client's skin
2. Makes sure that two fingers can be inserted under the restraint
The nurse is caring for a client with a wound infected with methicillin-resistant Staphylococcus aureus (MRSA). The most appropriate infection control precautions for MRSA include which intervention? 1. A room with positive-pressure airflow 2. Private room, gown, gloves, and face shield 3. Private room with negative-pressure airflow 4. Mask or respiratory protection device and gown
2. Private room, gown, gloves, and face shield
When administering an intramuscular (IM) injection in the gluteal muscle, how should the nurse position the client to best relax the muscle? 1. Sims with a toe-in position 2. Prone with a toe-in position 3. On the side with the knee of the uppermost leg flexed 4. On the side with the knee of the lowermost leg flexed
2. Prone with a toe-in position
The nurse is administering ear drops to a 2-year-old child. To follow the correct administration procedure, the nurse should perform which action? 1. Pulls the pinna of the ear back and up 2. Pulls the pinna of the ear back and down 3. Places the child in a prone position with the ear to receive the drop facing downward 4. Places the child in a side-lying position with the ear to receive the drop facing downward
2. Pulls the pinna of the ear back and down
The nurse is caring for a client with impaired mobility that occurred as a result of a stroke. The client has right-sided arm and leg weakness. Which assistive device should the nurse suggest that the client use to provide the best stability for ambulating? 1. Walker 2. Quad cane 3. Crutches 4. Single straight-legged cane
2. Quad cane
The nurse is planning to instruct a client with chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Which instruction should the nurse plan to include in the client's teaching plan? 1. Turn the head slowly when spoken to. 2. Remove throw rugs and clutter in the home. 3. Go to the bedroom and lie down when vertigo is experienced. 4. Drive only when feelings of dizziness have not been experienced for several hours.
2. Remove throw rugs and clutter in the home.
Two nurses are leaving the room of a client whose care required them to wear a gown, mask, and gloves. Which action by these nurses could lead to the spread of infection? 1. Taking off the gloves first before removing the gown 2. Removing the gown without rolling it from inside out 3. Washing the hands after the entire procedure has been completed 4. Removing the gloves and then removing the gown using the neck ties
2. Removing the gown without rolling it from inside out
The nurse is conducting a community surveillance study for the purpose of communicable disease control. The nurse knows that performing an active surveillance method of assessment is best for what reason? 1. Always results in clear indicators for interventions 2. Results in detection of a more accurate number of cases 3. Reflects an upward swing if a certain disease is current news 4. Relies solely on the initiative of health care providers (HCP) to report cases
2. Results in detection of a more accurate number of cases
A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor should the nurse include when responding to the client? 1. Five blood cultures are negative. 2. Three sputum cultures are negative. 3. A blood culture and a chest x-ray are negative. 4. A sputum culture and a Mantoux test are negative.
2. Three sputum cultures are negative.
The nurse is caring for an older client who had a hip pinned after being fractured. Which should the nurse do to prevent further injury? 1. Respond to the call light within 10 minutes. 2. Use a night light in the hospital room and the bathroom. 3. Medicate the client with a sleeping pill to encourage him or her to sleep through the night. 4. Keep all four side rails in the up position, preventing the client from getting out of bed.
2. Use a night light in the hospital room and the bathroom.
The nursing student develops a plan of care for a client with paraplegia who is at risk for injury related to spasticity of the leg muscles. On reviewing the plan, the co-assigned licensed nurse identifies which action as an incorrect intervention? 1. Using prescribed muscle relaxants as needed 2. Using padded restraints to immobilize the limb 3. Performing range-of-motion exercises to the affected limbs 4. Removing potentially harmful objects near the spastic limbs
2. Using padded restraints to immobilize the limb
A nurse is providing orientation to a newly graduated nurse. During a discussion of isolation procedures, which statement by the graduate nurse indicates a need for further review of isolation guidelines? 1. "A client with tuberculosis will be placed on airborne precautions." 2. "I will wear a mask when working with an isolated client who has a tracheostomy." 3. "I can reuse a gown if it's not dirty, as long as I hang it up inside the client's room." 4. "I will remove the gown and gloves and wash my hands before leaving the client's room."
3. "I can reuse a gown if it's not dirty, as long as I hang it up inside the client's room."
The nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the scouts about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further instructions? 1. "I need to bring a hat to wear during the trip." 2. "I should wear long-sleeved tops and long pants." 3. "I should not use insect repellents because it will attract the ticks." 4. "I need to wear closed shoes and socks that can be pulled up over my pants."
3. "I should not use insect repellents because it will attract the ticks."
A client is scheduled for insertion of a peripherally inserted central catheter (PICC) and the nurse explains the advantages of this catheter. Which statement by the client indicates a need for follow-up? 1. "It is reasonable in cost." 2. "This type of catheter is very reliable." 3. "It is specifically designed for short-term use." 4. "I should not have pain or discomfort with this catheter."
3. "It is specifically designed for short-term use."
A 7-year-old child is diagnosed with viral conjunctivitis. Antibiotic eye drops are prescribed for the child. When the mother asks the nurse when the child can return to school, what should the appropriate response be? 1. "The child can return to school immediately." 2. "The child cannot return to school until seen by the health care provider in 1 week." 3. "The child should be kept home until the antibiotic eye drops have been administered for 24 hours." 4. "The child should be kept home until the antibiotic eye drops have been administered for 72 hours."
3. "The child should be kept home until the antibiotic eye drops have been administered for 24 hours."
The nurse provides home care instructions to a client with sickle cell anemia. Which statement by the client indicates a need for further instruction? 1. "I'm going to take a painting class." 2. "I've learned to knit and sew my own clothes." 3. "When I'm feeling better, I'm returning to the soccer team." 4. "I'm using a schedule to maintain my increased fluid intake."
3. "When I'm feeling better, I'm returning to the soccer team."
The nurse is preparing to administer an intramuscular (IM) injection to a 4-year-old child. The nurse plans to administer the injection in the ventral gluteal muscle, knowing that which indicates the maximum amount of medication volume that can be safely injected? 1. 0.5 mL 2. 1.0 mL 3. 1.5 mL 4. 2.0 mL
3. 1.5 mL
The nurse is planning to teach a group of adolescents about the use of condoms as part of a risk-reduction program for sexually transmitted infections (STIs). The nurse should plan to include which recommendation in the teaching plan? 1. Condoms should not be lubricated. 2. Use condoms whenever the partner seems "risky." 3. Always apply the condom before inserting the penis into the vagina. 4. Natural membrane condoms can be used because they are just as effective as latex.
3. Always apply the condom before inserting the penis into the vagina.
The nurse is observing a second nurse perform hemodialysis on a client. The second nurse is drinking coffee and eating a doughnut next to the hemodialysis machine, while talking with the client about the events of his week. What is the nurse's most appropriate action regarding this observation? 1. Offer the client a cup of coffee. 2. Get a cup of coffee and join in on the conversation. 3. Ask the nurse to refrain from eating and drinking in that area. 4. Appreciate what a wonderful therapeutic relationship this nurse and client have.
3. Ask the nurse to refrain from eating and drinking in that area.
The nurse develops a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? 1. Out-of-bed activities as desired 2. Bed rest with the affected extremity kept flat 3. Bed rest with elevation of the affected extremity 4. Bed rest with the affected extremity in a dependent position
3. Bed rest with elevation of the affected extremity
A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action? 1. Induce vomiting. 2. Call an ambulance. 3. Call the Poison Control Center. 4. Bring the child to the emergency department.
3. Call the Poison Control Center.
A nurse is caring for a client who is on strict bed rest. The nurse develops a plan of care and develops goals related to the prevention of deep vein thrombosis (DVT) and pulmonary emboli. Which nursing action is most helpful to prevent these disorders from developing? 1. Restricting fluids 2. Placing a pillow under the knees 3. Encouraging active range-of-motion exercises 4. Applying a heating pad to the lower extremities
3. Encouraging active range-of-motion exercises
The nurse is giving a change-of-shift report. What is the primary purpose of a change-of-shift report? 1. Assess the client's status. 2. Plan care for the next shift. 3. Ensure continuity of care for the client. 4. Document the client's care for that shift.
3. Ensure continuity of care for the client.
A nursing student is assigned to administer an intramuscular iron injection to a client. The coassigned nurse asks the student about the technique for administration of this medication. The student indicates understanding of the administration procedure by identifying what as the correct injection site and method? 1. Anterolateral thigh using an air lock 2. Deltoid muscle using a 1-inch needle 3. Gluteal muscle using Z-track technique 4. Subcutaneous tissue of the abdomen using a 1-inch needle
3. Gluteal muscle using Z-track technique
A nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn infant. Which statement should the nurse make to the client? 1. Visitors are not allowed to hold the baby. 2. There is no danger of the newborn contracting the disease. 3. Hands should be washed thoroughly before holding the infant. 4. The newborn infant will not be allowed in the mother's room at all.
3. Hands should be washed thoroughly before holding the infant.
The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion? 1. Right side 2. Low Fowler's 3. High Fowler's 4. Supine with the head flat
3. High Fowler's
The nurse is assisting a female client to collect a midstream urine specimen. How should the nurse implement aseptic technique? 1. Cleansing the meatus with antiseptic pads using upward strokes 2. Letting go of the labia once this tissue is cleansed, to allow the client to urinate 3. Making sure that the fingers avoid touching the inside of the collection container 4. Instructing the client to urinate in the container after the labia have been cleansed
3. Making sure that the fingers avoid touching the inside of the collection container
The registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action? 1. Mark the tube at 10 inches. 2. Mark the tube at 32 inches. 3. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process. 4. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum.
3. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process.
A nurse is preparing a plan of care for a client with a diagnosis of agranulocytosis who is being admitted to the hospital. The nurse determines that which is the priority when formulating the client's plan of care? 1. Fatigue 2. Constipation 3. Potential for infection 4. Insufficient knowledge
3. Potential for infection
A client who is receiving therapy with a hypothermia blanket starts to shiver. The nurse raises the blanket temperature and monitors the client. After 15 minutes the client's temperature has not increased and the client is still shivering. What should the nurse do next? 1. Apply a smaller heating pad to the client's axillae and neck areas. 2. Wait 10 more minutes and then check the client's temperature again. 3. Remove the hypothermia blanket and notify the client's health care provider (HCP). 4. Increase the blanket's temperature again and recheck the client's temperature in 15 minutes.
3. Remove the hypothermia blanket and notify the client's health care provider (HCP).
The nurse is providing mouth care to an unconscious client. The nurse should avoid which action during this procedure? 1. Turning the head to one side 2. Using oral suction equipment 3. Rinsing with a large volume of fluid 4. Using a bite stick or padded tongue blade
3. Rinsing with a large volume of fluid
The nurse is caring for a restless client who is beginning nutritional therapy with parenteral nutrition (PN). The nurse should plan to ensure that which action is taken to prevent the client from sustaining injury? 1. Calculate daily intake and output. 2. Monitor the temperature once daily. 3. Secure all connections in the PN system. 4. Monitor blood glucose levels every 12 hours.
3. Secure all connections in the PN system.
A client receiving parenteral nutrition (PN) suddenly develops a fever. The nurse notifies the health care provider (HCP), and the HCP initially prescribes that the solution and tubing be changed. What should the nurse do with the discontinued materials? 1. Discard them in the unit trash. 2. Return them to the hospital pharmacy. 3. Send them to the laboratory for culture. 4. Save them for return to the manufacturer.
3. Send them to the laboratory for culture.
The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy? 1. Restrict all visitors. 2. Restrict fluid intake. 3. Teach the client and family about the need for hand hygiene. 4. Insert an indwelling urinary catheter to prevent skin breakdown.
3. Teach the client and family about the need for hand hygiene.
The home care nurse visits a client at home who has been experiencing increased weakness. The client tells the nurse that he is using a cane that was purchased at a local pharmacy. The home care nurse assesses the client's use of the cane and determines that the cane is sized correctly if which observation is made? 1. The handle of the cane is even with the client's waist. 2. The client's elbow is straight when ambulating with the cane. 3. The client's elbow is flexed at a 15- to 30-degree angle when ambulating with the cane. 4. The client's elbow is flexed at a 50- to 75-degree angle when ambulating with the cane.
3. The client's elbow is flexed at a 15- to 30-degree angle when ambulating with the cane.
A nurse is assessing the extremities of a client who had wrist restraints applied 2 hours ago. Which assessment finding, if present, is of greatest concern? 1. The client is able to wiggle the fingers. 2. The restraint is secured to the bed's frame. 3. The skin of the hand feels cool to the touch and is pale. 4. The nurse is able to insert two fingers under the restraints between the restraint and the client's skin.
3. The skin of the hand feels cool to the touch and is pale.
The nurse is caring for an older client with dysphagia who is at risk for aspiration. When preparing the client for eating, the nurse should place the client in which position to minimize the risk for aspiration? 1. Low Fowler's 2. On the left side 3. Upright in a chair 4. On the right side
3. Upright in a chair
The nurse is supervising an unlicensed assistive personnel (UAP) performing mouth care on an unconscious client. The nurse should intervene if the UAP is observed taking which action? 1. Turning the client's head to one side 2. Using small volumes of fluid to rinse the mouth 3. Using a gloved finger to open the client's mouth 4. Placing an emesis basin under the client's mouth
3. Using a gloved finger to open the client's mouth
The home health nurse visits a client with suspected scabies. Which precaution should the nurse institute during the assessment of the client? 1. Wear gloves only. 2. Wear a mask and gloves. 3. Wear a gown and gloves. 4. Avoid touching the client's home furnishings.
3. Wear a gown and gloves.
Which action by the parent of an infant with respiratory syncytial virus infection who is receiving ribavirin (Virazole) would indicate a need for further instruction regarding the management of the disease process? 1. Wearing protective garb when visiting the infant 2. Washing the hands before leaving the infant's room 3. Telling a family member who has asthma that he should not visit the infant 4. Telling the infant's aunt who is pregnant that it is acceptable to visit the infant
4. Telling the infant's aunt who is pregnant that it is acceptable to visit the infant
An adolescent is diagnosed with conjunctivitis, and the nurse provides information to the adolescent about the use of contact lenses. Which statement by the client would indicate the need for further information? 1. "I should not wear my contact lenses." 2. "New contact lenses should be obtained." 3. "My old contact lenses should be discarded." 4. "My contact lenses can be worn if they are cleaned as directed."
4. "My contact lenses can be worn if they are cleaned as directed."
The nurse is completing medication reconciliation with a client just before his or her discharge to home. The client asks, "Why are you going over this list? They did that when I was admitted!" Which statement by the nurse is the best response? 1. "Medication reconciliation is required before you can go home." 2. "Your insurance company requires a list of medications that you will be taking." 3. "We are checking to see what medications can be discontinued before you go home." 4. "We do this to make sure you will be receiving the correct medications once you are at home."
4. "We do this to make sure you will be receiving the correct medications once you are at home."
The nurse is preparing to care for a client with esophageal varices who needs a Sengstaken-Blakemore tube inserted because other treatments were unsuccessful. The nurse gathers supplies, knowing that which item must be kept at the bedside at all times? 1. An obturator 2. A Kelly clamp 3. An irrigation set 4. A pair of scissors
4. A pair of scissors
The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted? 1. A clotting time of 10 minutes 2. An ammonia level of 20 mcg/dL 3. A platelet count of 50,000 cells/mm3 4. A white blood cell count of 5000 cells/mm3
4. A white blood cell count of 5000 cells/mm3
A nurse is assigned to care for a client who is experiencing episodes of postural hypotension. Which action should the nurse take to ensure safety while transferring the client from the bed to the chair? 1. Arrange for a transfer board to be used. 2. Perform the transfer using a hydraulic lift only. 3. Put the client's shoes on so that the client will not slip on the floor during the transfer. 4. Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.
4. Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.
The nurse has administered an injection to a client. After the injection, the nurse accidentally drops the syringe on the floor. What is the most appropriate nursing action in this situation? 1. Obtain a dust pan and mop to sweep up the syringe. 2. Call the housekeeping department to pick up the syringe. 3. Carefully pick up the syringe from the floor and gently recap the needle. 4. Carefully pick up the syringe from the floor and dispose of it in a sharps container.
4. Carefully pick up the syringe from the floor and dispose of it in a sharps container.
The nurse is administering enteral feedings via a nasogastric (NG) tube. The nurse should take which action when caring for this client to maintain client safety? 1. Maintain the client in a supine position. 2. Change the NG tube with every other feeding. 3. Increase the rate of the feeding if the infusion falls behind schedule. 4. Check for tube placement and residual amount at least every 4 hours.
4. Check for tube placement and residual amount at least every 4 hours.
A nurse has a prescription to administer phenytoin (Dilantin) by intravenous push (IVP) through an IV line infusing 1000 mL of 0.9% sodium chloride. Arrange the actions in the order that they should be performed. All options much be used. 1. Check the client's identification (ID) bracelet. 2. Pinch off the IV tubing above the injection port. 3. Draw up the medication in a 3-mL syringe. 4. Check the compatibility of phenytoin with the IV solution. 5. Inject the medication. 6. Document that the medication was administered.
4. Check the compatibility of phenytoin with the IV solution. 3. Draw up the medication in a 3-mL syringe. 1. Check the client's identification (ID) bracelet. 2. Pinch off the IV tubing above the injection port. 5. Inject the medication. 6. Document that the medication was administered.
A client is receiving outpatient radiation treatments for carcinoma of the oropharynx and is experiencing dysphagia. The nurse should include which intervention in the plan of care? 1. Encourage the client to drink only thin liquids. 2. Teach the client to examine his oral mucosa monthly. 3. Teach the client to speak slowly and enunciate clearly. 4. Encourage the client to use artificial saliva to manage dryness.
4. Encourage the client to use artificial saliva to manage dryness.
A client with right leg hemiplegia has a problem with mobility. The nurse determines a need for reinforcement of teaching the client and the client's family if the nurse observes which action being done by the family? 1. Applying a premolded splint 2. Active range of motion to the affected leg 3. Passive range of motion to the affected leg 4. Encouraging the client to stand unassisted on the leg
4. Encouraging the client to stand unassisted on the leg
The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention if noted in the plan indicates the need for revision of the plan? 1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a lead apron when providing direct care to the client 4. Placing the client in a semiprivate room at the end of the hallway
4. Placing the client in a semiprivate room at the end of the hallway
The nurse is inserting a nasogastric (NG) tube into an adult client. During the procedure, the client begins to cough and have difficulty breathing. The nurse should take which priority action? 1. Remove the tube, and notify the health care provider. 2. Instruct the client to hold their breath and insert the NG tube. 3. Remove the tube, and reinsert when the client fully recovers. 4. Pull back on the tube, and wait until the client is breathing easily.
4. Pull back on the tube, and wait until the client is breathing easily.
A nurse has called a client's primary health care provider to clarify a medication prescription. The health care provider gives a telephone prescription to the nurse for a new medication. What action by the nurse would best promote accuracy at this time? 1. Ensure that the prescription is written neatly. 2. Double-check the prescription with another registered nurse. 3. Call the pharmacy to verify the accuracy of the prescribed medication. 4. Read the prescription back to the health care provider after writing it on the prescription sheet.
4. Read the prescription back to the health care provider after writing it on the prescription sheet.
A nurse in the ambulatory care department hears a client in the waiting room call out, "Help, fire!" The nurse rushes to the waiting room and finds the wastebasket on fire. Which action should the nurse take first? 1. Extinguish the fire. 2. Activate the fire alarm. 3. Confine the fire and then call 911. 4. Remove the client from the waiting room.
4. Remove the client from the waiting room.
A nurse has a written prescription to discontinue an intravenous (IV) line. The nurse obtains which item from the unit supply area for use in applying pressure to the site after removing the IV catheter? 1. Band-Aid 2. Alcohol swab 3. Betadine swab 4. Sterile 2 × 2 gauze
4. Sterile 2 × 2 gauze
A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position? 1. Prone 2. Reverse Trendelenburg's 3. Supine, with the amputated limb flat on the bed 4. Supine, with the amputated limb supported with pillows
4. Supine, with the amputated limb supported with pillows
The nurse is preparing to initiate an intravenous (IV) puncture on a client and obtains the prescribed solution of 1000 mL of normal saline for the infusion. The nurse sets up the IV infusion and checks which before performing the venipuncture? 1. The client's temperature 2. The client's blood pressure 3. The client's electrolyte values 4. The IV solution for particles or contamination
4. The IV solution for particles or contamination
A client is being discharged to home after 2 weeks with a diagnosis of tuberculosis and is worried about the possibility of infecting family members and others. How should the nurse respond to provide reassurance? 1. The family does not need therapy, and the client will not be contagious after 1 month of drug therapy. 2. The family does not need therapy, and the client will not be contagious after 6 consecutive weeks of drug therapy. 3. The family will be treated prophylactically, and the client will not be contagious after 1 continuous week of drug therapy. 4. The family will be treated prophylactically, and the client will not be contagious after 2 to 3 consecutive weeks of drug therapy.
4. The family will be treated prophylactically, and the client will not be contagious after 2 to 3 consecutive weeks of drug therapy.
The community health nurse is performing a safety assessment in the home of a mother with two children, ages 1 and 3 years. Which, if noted during the assessment, presents the greatest hazard to the children? 1. Small dog as a house pet 2. Hot water heater set above 120° F 3. Gate placed at the stairs of the second floor 4. Toys with small loose parts in the playroom
4. Toys with small loose parts in the playroom
The school nurse prepares a list of home care instructions for the parents of schoolchildren diagnosed with pediculosis capitis. Which instruction should the nurse include in the list? 1. Soak combs and brushes in warm water. 2. Use anti-lice sprays on all bedding and furniture. 3. Take all bedding and linens to the cleaners to be dry cleaned. 4. Vacuum floors, play areas, and furniture to remove any hairs that might carry live nits.
4. Vacuum floors, play areas, and furniture to remove any hairs that might carry live nits.
The nurse is giving a bed bath to a client and discovers that an additional washcloth and towel are needed. Which is the most appropriate action to take to obtain the needed items? 1. Ask the unit secretary to get the needed items. 2. Ask a family member to obtain the needed items. 3. Borrow the client's roommate's washcloth and towel. 4. Wash hands, leave the client's room, and obtain the needed items.
4. Wash hands, leave the client's room, and obtain the needed items.
A nurse is making a note in the care plan for a client who has a multilumen central venous catheter. The nurse should write to change the injection caps on the lumens at which times? 1. Once a week 2. At the change of each shift 3. After administration of each medication 4. Whenever blood is drawn from the lumen
4. Whenever blood is drawn from the lumen
A client has been receiving a series of medications as part of intravenous antineoplastic therapy. The nurse should implement neutropenic precautions after noting which laboratory result for this client? 1. Clotting time of 10 minutes 2. Ammonia level of 20 mcg/dL 3. Platelet count of 100,000 cells/mm3 4. White blood cell (WBC) count of 2000 cells/mm3
4. White blood cell (WBC) count of 2000 cells/mm3
A client has a fiberglass cast applied to the lower leg. The client asks the nurse when the client will be able to walk using the casted leg. The nurse replies that the client will be able to bear weight on the casted leg in which time period? 1. In 24 hours 2. In 48 hours 3. In about 8 hours 4. Within 20 to 30 minutes of application
4. Within 20 to 30 minutes of application
The nurse is caring for a child who will require the use of an apnea monitor when discharged from the hospital. Which information should the nurse provide to the child's caregiver about the use of an apnea monitor? Select all that apply. 1. Keep leads on the child at all times. 2. Place the monitor inside the child's crib. 3. Adjust the monitor to eliminate false alarms. 4. Sleep in the same bed as the monitored infant. 5. Keep pets and children away from the monitor. 6. Keep emergency rescue numbers near the telephone.
5. Keep pets and children away from the monitor. 6. Keep emergency rescue numbers near the telephone.
