Saunders Exam- Safe and Effective Care Environment Exam

The nursing instructor asks the nursing student to identify the priorities of care for an assigned client. The nursing instructor determines that the nursing student understands the client's needs when which statement is made?

"Actual or life-threatening concerns are the priority."

A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply.

"I keep reliving the robbery." "I see his face everywhere I go." "I might have died over a few dollars in my pocket."

Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction?

"I will ask the nurse to attend to my infant if I am napping and my husband is not here."

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?

Ask the nurse to refrain from eating and drinking in that area.

Which should the nurse do when setting up an arterial line?

Tighten all tubing connections.

The home care nurse is visiting a client who sustained a severe muscle sprain to the back. Carisoprodol is prescribed for the client. The nurse provides instructions to the client regarding the medication and should teach the client to take which measure?

To avoid driving until the reaction to the medication is known

An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response?

"As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

The home care nurse visits a client who has delivered a healthy newborn infant via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the client regarding care related to the infection. Which statement, if made by the mother, indicates a need for further instruction?

"I need to isolate the infant for 48 hours after beginning the antibiotics." Rationale: The infant is not isolated routinely from the mother with a wound infection, but the mother must be taught good hand-washing techniques and how to protect the infant from contact with contaminated articles. If the mother has a wound infection, broad-spectrum antibiotics will be prescribed for the mother, and she should be instructed to take the antibiotics as prescribed. Analgesics are often necessary, and sitz baths or warm compresses may be used to provide comfort in the area. There is no need to isolate the infant.

A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which response by the nurse is most appropriate?

"I will call the nursing supervisor for assistance regarding your request."

While making rounds a client asks the nurse, "What's wrong with that lady in the room next to me? She cries out all night long, and I hope she is okay." What is the nurse's best response?

"I'm sure it's upsetting to hear her cry, but I'm not able to discuss details about other clients."

The experienced nurse is observing a newly hired graduate nurse count opioids as part of the orientation process. The experienced nurse determines that the newly hired nurse needs further teaching about the procedure for counting opioids when which statement is made?

"If a portion of an opioid is used, it is okay to leave it in the client's drawer to use at another time during the shift."

The nurse prepares a teaching plan for the mother of a child diagnosed with bacterial conjunctivitis. Which, if stated by the mother, indicates a need for further teaching?

"It is okay to share towels and washcloths."

The nurse is caring for a pregnant woman who has herpes genitalis. The nurse provides instructions to the woman about treatment modalities that may be necessary for this condition. Which statement made by the woman indicates an understanding of these treatment measures?

"It may be necessary to have a cesarean section for delivery."

A client is being discharged to home after spinal fusion with insertion of instrumentation (rod). The unit nurse should consult with the continuing care nurse regarding the need for modification of the home environment if the client makes which statement?

"My bedroom and bathroom are on the second floor of my home."

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?

"My wife should get the vaccine."

A child is seen in a health care clinic, and a diagnosis of chickenpox is confirmed. The mother expresses concern for two other children at home and asks the nurse if the child is infectious to the other children. Which response by the nurse is most appropriate?

"The infectious period begins 1 to 2 days before the onset of the rash and ends about 5 days after the onset of the lesions and crusting of the lesions."

The nurse manager is giving a staff in-service on providing culturally sensitive education to clients. Which statements indicate to the nurse manager that the staff understands providing culturally sensitive education? Select all that apply.

"The population served will determine the culturally sensitive resources to use for teaching." "Assessment of a client's preferred learning approach is essential to facilitate the learning process." "It is important to have an accurate translator when the nurse and client do not speak the same language."

The nurse provides instructions regarding home care to the parents of a 3-year-old child hospitalized with hemophilia. Which statement, if made by the parent, indicates a need for further instructions?

"We will avoid having our child receive immunizations."

The nurse notes that an infant with the diagnosis of hydrocephalus has a head that is heavier than that of the average infant. The nurse should determine that special safety precautions are needed when moving the infant with hydrocephalus. Which statement should the nurse plan to include in the discharge teaching with the parents to reflect this safety need?

"When picking up your infant, support the infant's neck and head with the open palm of your hand."

The rubella vaccine has been prescribed for a new mother. Which statements should the postpartum nurse make when providing information about the vaccine to the client? Select all that apply.

"You need this vaccine because you are not immune to the rubella virus." You should not become pregnant for 1 to 3 months after the administration of the vaccine."

The nurse is counseling the young mother of a small child recently diagnosed with impetigo. The nurse should make which statement that provides the best information about impetigo?

"You will need to prevent any of the fluid from the blisters from coming into contact with your other children."

The nurse is reviewing the results of the rubella screening (titer) with a pregnant client. The test results are positive, and the mother asks if it is safe for her toddler to receive the vaccine. What is the nurse's best response?

"Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time."

The nurse is assigned to the following clients. The nurse would assess the clients in which order of priority? Place the client in the order of priority for assessment. All options must be used.

1. A client with heart failure who has a 4-lb weight gain since yesterday and is experiencing shortness of breath 2. A 24-hour postoperative client who had a wedge resection of the lung and has a closed chest tube drainage system 3. A client admitted to the hospital for observation who has absent bowel sounds 4. A client who is undergoing surgery for a hysterectomy on the following day

Which client situation is most appropriate for the nurse to consult with the Rapid Response Team (RRT)?

A 45-year-old client, 2 years after kidney transplant, second hospital day for treatment of pneumonia, no urine output for 6 hours, temperature 101.4º F (38.6º C), heart rate 98 beats/min, respirations 20 breaths/min, blood pressure 168/94 mm Hg

An emergency department nurse is preparing to receive 4 clients as a result of a motor vehicle crash. Which victim should the nurse attend to first?

A 45-year-old man with chest pain, shortness of breath, and diaphoresis

The nurse is caring for 4 pediatric clients. After receiving reports from the night shift, which child should the nurse assess first?

A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected

The registered nurse is creating the plan for client assignments for the day. Which is the most appropriate assignment for the assistive personnel (AP)?

A client on bed rest who requires range-of-motion (ROM) exercises every 4 hours

The registered nurse (RN) is planning client assignments and cannot take a client assignment today. Two assistive personnel (AP) and a licensed practical nurse (LPN) also are assigned to the unit. Which client should the RN most appropriately assign to the LPN?

A client scheduled for a cardiac catheterization

The nurse working in the emergency department has four charts of clients who need to be assessed. Which client should be assessed first?

A client with a history of schizophrenia threatening to harm himself

The nurse is conducting home visits with a head-injured client with residual cognitive deficits. The client has problems with memory, has a shortened attention span, is easily distracted, and processes information slowly. The nurse plans to talk with the primary health care provider about referring the client to which professional?

A neuropsychologist

The nurse is the first responder at the scene of a 6-car crash on a highway. Which victim should the nurse attend to first?

A victim experiencing dyspnea

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees to identify which client as most typically a victim of abuse?

A woman who has advanced Parkinson's dise

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify which client as most typically a victim of abuse?

A woman who has advanced Parkinson's disease

The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action?

Activate the emergency response plan.

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply.

Activities should be resumed gradually. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. Respiratory isolation is not necessary, because family members already have been exposed. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.

The nurse is preparing the client assignment. Which should be assigned to a licensed practical nurse (LPN)?

Administration of a new oral medication to a client with Alzheimer's disease

A child with rubeola (measles) is being admitted to the hospital. In preparing for the admission of the child, the nurse should plan to place the child on which precautions?

Airborne

An assistive personnel (AP) is caring for a client who has an indwelling urinary catheter. Which action by the AP would indicate the need for further instruction in the care of the client?

Allowed the drainage tubing to rest under the leg

A client is admitted to the ambulatory surgery center for elective surgery. The nurse asks the client whether any food, fluid, or medication was taken today. Which medication, if taken by the client, should indicate to the nurse the need to contact the surgeon?

An anticoagulant

The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times?

At least 30 minutes before exposure to the sun

The nurse who is caring for a client with myasthenia gravis has a prescription to perform an edrophonium test. After obtaining edrophonium the nurse should be certain that which also is available at the bedside?

Atropine sulfate

A filled blood specimen tube was dropped and broken in the client's room. Which action performed by the assistive personnel to clean up the blood spill is incorrect?

Blots up the spill with a face cloth or cloth towel

The nurse from a medical unit is called to assist with care for clients coming into the hospital emergency department during an external disaster. Using principles of triage during a disaster, the nurse should attend to the client with which problem first?

Bright red bleeding from a neck wound

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take?

Call the nursing supervisor.

A hospitalized client with a history of alcohol misuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take?

Call the nursing supervisor.

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?

Change the IV tubing.

The nurse reviews the primary health care provider's (PHCP's) prescriptions for a client with Guillain-Barré syndrome. Which prescription written by the PHCP should the nurse question?

Clear liquid diet

The nurse is interviewing a client in crisis to assess the risk for self-harm. The nurse interprets that the client is most at risk for suicide when which factor is identified?

Client has an immediate plan for a suicide attempt.

Which interventions should the nurse take for a deceased client whose eyes will be donated? Select all that apply.

Close the client's eyes. Elevate the head of the bed. Place wet saline gauze pads and a cool pack on the eyes.

A primary health care provider (PHCP) prescribes quinidine gluconate for a client. The nurse decides to withhold the medication and contact the PHCP if which assessment finding is documented in the client's medical record?

Complete atrioventricular (AV) block Rationale: Quinidine gluconate is an antidysrhythmic medication used to maintain normal sinus rhythm after conversion of atrial fibrillation or atrial flutter. It is contraindicated in complete AV block, intraventricular conduction defects, and abnormal impulses and rhythms caused by escape mechanisms, and with myasthenia gravis. It is used with caution in clients with preexisting muscle weakness, asthma, infection with fever, and hepatic or renal insufficiency.

The nurse calls the primary health care provider (PHCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action should the nurse take?

Contact the nursing supervisor.

The nurse working in a same-day procedure unit is admitting a client scheduled for an arthrogram using a contrast medium. Which is the prioritynursing assessment for this client?

Determine if the client has an allergy to iodine or shellfish.

The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which actions to correct the error? Select all that apply.

Draw 1 line through the error, initialing and dating it. Document the correct information and end with the nurse's signature and title.

The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions?

Droplet

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?

Encouraging the client to stand unassisted on the leg

The nurse is giving report to an assistive personnel (AP) who will be caring for a client in hand restraints (safety devices). How frequently should the nurse instruct the AP to check the tightness of the restrained hands?

Every 30 minutes

The nurse is reviewing a primary health care provider's prescriptions for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? Select all that apply.

Give meperidine, 25 mg intravenously, every 4 hours for pain. Restrict fluid intake.

The student nurse is presenting a clinical conference regarding human immunodeficiency virus (HIV) in children. Which information should the student include?

HIV cannot be spread by hugging, holding, or touching other people.

A client with pulmonary tuberculosis (TB) is on airborne isolation precautions. Which item(s) is essential for the nurse to wear?

High-efficiency particulate air (HEPA) filter mask

The student nurse is caring for an infant with a tracheostomy and is preparing to suction the infant. The nursing instructor should intervene if the nursing student stated she would take which action to perform this procedure?

Limit insertion and suctioning time to 15 seconds to prevent hypoxia.

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care?

Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

The nurse creates a plan of care for a woman with human immunodeficiency virus (HIV) infection and her newborn. The nurse should include which intervention in the plan of care?

Maintaining standard precautions at all times while caring for the newborn

During the assessment, what is the nurse's primary goal for a confused and disoriented client diagnosed with post-traumatic stress disorder?

Making the client feel safe

The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles?

Mask

The nurse is caring for a hospitalized child with a diagnosis of measles (rubeola). In preparing to care for the child, which supplies should the nurse bring to the child's room to prevent transmission of the virus?

Mask and gloves

A registered nurse (RN) is supervising a licensed practical nurse (LPN) administering an intramuscular (IM) injection of iron to an assigned client. The RN would intervene if the LPN is observed performing which action?

Massaging the injection site after injection

Which home care instructions should the nurse provide to the parent of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply.

Monitor the child's weight. Frequent hand washing is important. The child should avoid exposure to other illnesses. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach).

The nurse is evaluating a client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performs which action?

Moves the cane when the right leg is moved Rationale: The cane is held on the stronger side to minimize stress on the affected extremity and to provide a wide base of support. The cane is held 4 to 6 inches (10 to 15 cm) lateral to the fifth toe. The cane is moved forward with the affected leg. The client leans on the cane for added support while the leg on the stronger side swings through.

The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the primary health care provider's (PHCP's) prescriptions and should contact the PHCP to question which prescription?

Nasotracheal suction as needed. Rationale: Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture: Because of the nature of the injury, there is a possibility that the catheter will enter the brain through the fracture, creating a high risk of secondary infection.

The nurse is reviewing the primary health care provider's (PHCP's) prescriptions for a client recently admitted to the hospital and notes that the PHCP has prescribed ticlopidine therapy. Which finding on the client's record would indicate a need to contact the PHCP before initiating the medication prescription?

Neutropenia Rationale: Neutropenia, or agranulocytosis, is the most serious adverse effect associated with the use of ticlopidine. A baseline complete blood cell (CBC) count with differential will be performed for the client. Neutropenia occurs most often within the first 3 months of therapy; therefore, a CBC with differential is recommended every 2 weeks during the first 3 months. If a diagnosis of neutropenia is determined, the client will be withdrawn from therapy. This medication is used to prevent a stroke and is not contraindicated in hypertension.

The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care?

One-to-one suicide precautions

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply.

Padding the side rails of the bed. Placing an airway at the bedside. Placing oxygen and suction equipment at the bedside. Flushing the intravenous catheter to ensure that the site is patent.

A client in shock is receiving dopamine hydrochloride by intravenous (IV) infusion. The nurse should have which medication available for local injection if IV infiltration and medication extravasation occur?

Phentolamine

The registered nurse (RN) directs the licensed practical nurse (LPN) to assist with the care of a client who has a sacral ulcer. Which is the most appropriate activity for the RN to delegate to the LPN?

Place the client in a side-lying position.

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply

Place the infant in a private room. Wear a mask at all times when in contact with the infant. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.

The nurse is acting in the role of client advocate in which situations? Select all that apply.

Promoting client comfort Questioning primary health care provider prescriptions Supporting a client decision regarding a health care choice

The nurse has called a client's primary health care provider (PHCP) to clarify a medication prescription. The PHCP gives a telephone prescription to the nurse for a new medication. What action by the nurse would best promote accuracy at this time?

Read the prescription back to the PHCP after writing it on the prescription sheet.

At the beginning of the work shift, the nurse assesses the status of the client wearing a halo device. The nurse determines that which assessment finding requires intervention?

Red skin areas under the jacket Rationale: Red skin areas under the jacket indicate that the jacket is too tight. The resulting pressure could lead to altered skin integrity and needs to be relieved by loosening the jacket.

Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk for infection? Select all that apply.

Reduce exposure to environmental organisms. Use strict aseptic technique for all procedures. Ensure that anyone entering the child's room wears a mask.

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client?

Remain with the client until the anxiety decreases.

The nurse is caring for a client with acute glomerulonephritis. The nurse instructs the assistive personnel (AP) to implement which action when caring for the client?

Remove the water pitcher from the bedside.

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action?

Removing the client from any immediate danger

The nurse is caring for a client recovering from a subtotal thyroidectomy. Which supplies should be readily accessible for the care of this client? Select all that apply.

Suction supplies Calcium gluconate Tracheostomy tube insertion set

The nurse is reviewing the primary health care provider's prescriptions for a child following a tonsillectomy. Which prescription should the nurse question?

Suction the child frequently if coughing.

The nurse has received her client assignment for the day. Which client should the nurse care for first?

The 53-year-old client with heart failure who has gained 4 lb (1.8 kg) since yesterday and is short of breath

The clinic nurse is reviewing the primary health care provider's prescription for a child who has been diagnosed with scabies. Lindane has been prescribed for the child. The nurse questions the prescription if which is noted in the child's record?

The child is 18 months old. Rationale: Lindane is a pediculicide product that may be prescribed to treat scabies. It is contraindicated for children younger than 2 years because they have more permeable skin, and high systemic absorption may occur, placing the children at risk for central nervous system toxicity and seizures. Lindane also is used with caution in children between the ages of 2 and 10 years. Siblings and other household members should be treated simultaneously.

The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply.

The client has a history of intravenous drug use. The client has a history of sexually transmitted infections.

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report?

The client was found lying on the floor.

The nurse is the first responder at the scene of an accident in which a tire blowout caused a bus to roll over several times. Which victim should the nurse attend to first?

The confused 12-year-old with bright red blood pulsing from an open fracture of the femur

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?

Three sputum cultures are negative. RATIONALE- The client with tuberculosis must have sputum cultures performed every 2 to 4 weeks after initiation of antituberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative, because the client is considered noninfectious at that point.

The community health nurse is performing a safety assessment in the home of a mother with 2 children, ages 1 and 3 years. Which, if noted during the assessment, presents the greatest hazard to the children?

Toys with small loose parts in the playroom

An older client diagnosed with delirium becomes agitated and confused at night. Which action should be the nurse's most important strategy to minimize the client's risk for injury?

Turn off the television and radio, and use a night-light.

Nursing care of the child with myelosuppression from leukemia or chemotherapeutic agents should include which intervention?

Use good hand-washing technique.

The nurse is admitting a client who is suspected of having tuberculosis (TB) to the nursing unit. The nurse should plan to admit the client to a room that has which properties?

Venting to the outside, 6 air exchanges per hour, and ultraviolet light

A client has begun a course of therapy with rifampin. The home care nurse instructs the client on which measure due to an anticipated side effect?

Wear dark clothing to avoid staining.

The primary health care provider (PHCP) prescribes exenatide for a client with type 1 diabetes mellitus who takes insulin. The nurse should plan to take which most appropriateintervention?

Withhold the medication and call the PHCP, questioning the prescription for the client.