BC

The nurse is working with three clients from all socioeconomic levels, in the day room of the nursing home. Each one has a similar request of the nurse. The nurse responds first to the client whose son is the mayor of the city. Which ethical principle may be compromised with the nurse's action?

Justice / It seems that the client with the higher social status is getting preferred treatment. The ethical principle of justice means that treatment is equally applied or applied based on need

Always collect data about the physiologic problem first

Once a physiologic cause is removed as the cause other data should be collected

metabolic alkalosis

Weakness

Liver

Right

palliative care

Care designed not to treat an illness but to provide physical and emotional comfort to the patient and support and guidance to his or her family.

paresthesia

abnormal sensation of numbness and tingling without objective cause

mydriasis

dilation of the pupil

angioplasty

surgical repair of a blood vessel

A client with a history of eczema has been admitted with cellulitis of the left forearm. Which admission order should the nurse question immediately?

1. Start IV of normal saline at 100 mL per hour. 2. Keep left arm elevated on pillow at all times. 3. Apply ice packs to affected area every shift. 4. Ibuprophen 800 mg po every 6 hours prn pain.3 / Consider the process of cellulitis in the body. You are aware that this is a bacterial infection, usually caused by either staphylococcus or streptococcus, in an open would that was not properly cleaned or treated at the time. This client has a history of eczema, which means there may be many areas of inflamed, itchy dry skin that can easily become infected without proper care. In this scenario, the client's condition is serious enough to require hospitalization, either to prevent or to treat sepsis. Think about what cellulitis looks like: a warm, red, inflamed area of skin, noted here to be the left forearm, where the skin may be taunt and shiny from edema. How should you care for this client? After giving that some thought, look at the Healthcare provider's orders. What order would you question, and be sure you know why. It is crucial to understand the reasons behind specific actions in order to provide good nursing care. When reading all the options, remember that you are looking for an order the nurse should question - you are looking for something incorrect. Therefore, if you as the nurse would implement a particular order, it's not the answer you are looking for! Option 1: Is there anything wrong with this order? A client is in the hospital with cellulitis of the left forearm, and is to be started on an IV of normal saline. Okay, that is a basic isotonic solution that is generally acceptable in most situations. Were you thinking about the rate? This client may be bordering on sepsis, and is certainly sick enough to be hospitalized; therefore, 100 mL/hour is quite reasonable. No problem here. Try another option. Option 2: Cellulitis is an infection in the tissues, which means pain, warmth, redness, and a lot of swelling. The minute you see "swelling", you should think about taunt skin, tightness, and impaired circulation with possible permanent damage. So how do you decrease edema? The first step is to elevate the area, in this case the left forearm. Most often the easiest solution is to place the extremity up on one of two pillows, so that the area of swelling is higher than the level of the heart. Some facilities provide wedge shaped foam bolsters of cushions for elevation since they are less likely to slip out of place. This seems like a perfectly appropriate order too! Option 3: Does something seem not quite right here? Very good! Errors can occur in admission orders, and it is the responsibility of each nurse to carefully review orders, and more importantly, understand the why behind each order! On the surface, ice packs might sound like a comforting and cooling treatment for those hot, inflamed and painful areas of skin. But what happens when ice is applied? Vasoconstriction occurs, which would further impair the circulation and decrease healing in the affected areas. The nurse knows that warm, moist compresses applied a couple times a shift would actually improve circulation, decrease edema and speed healing. This is the order the nurse needs to question! Option 4: Anytime you think about swelling in a body part, remember that there is generally also pain. This client has a history of eczema and now has cellulitis in those fragile tissues. The edema and infection would definitely cause discomfort for this client that requires pain medication. The primary healthcare provider has ordered 800 mg. Ibuprophen every 6 hours as needed for pain. This dose may seem large but it is the prescription dose and every six hours is appropriate for pain control. No need to question this order.

Four clients are admitted to the medical-surgical unit. The nurse is aware that what client will need standard precautions only?

1. The client with chicken pox. 2. The client with rubeola. 3. The client with impetigo. 4. The client with pancreatitis. 4. Think about the specifics regarding infection control techniques in a hospital setting. You will recall that all clients start with standard precautions (formally called universal precautions), which means nurses must be very conscientious about hand washing and the use of gloves while providing care. But there are special circumstances that require additional precautions, such as the use of gowns, goggles or face shields. As a nurse, it is important to understand how diseases are transmitted in order to determine which specific precautions will protect staff and visitors. Although special isolation or personnel protective equipment (PPE) are usually prescribed by the primary healthcare provider, it is the responsibility of the nurse to verify that the prescription has been written. Also, the nurse is responsible to tell family or visitors the correct method of using PPE, which includes disposing of the PPE in the room before leaving and thorough hand washing. In this question, the nurse has multiple new clients being admitted with a variety of infectious illnesses that need specific infection precautions. You are looking for a client that needs only basic standard precautions. This question does not ask about what client may be in a private room. However, if that comes up in a question, do not think about a shortage of private rooms in the real world for isolation. In the NCLEX® world, the nurse has everything needed for safe care, including enough PPE and isolation rooms. Option 1: Definitely not. Chicken pox, also called varicella roster, is transmitted by droplets that the client coughs, sneezes, or breathes into the air. This client will need airborne precautions, which means the nursing staff should use gloves, gown, and face protection such as mask and goggles. These contaminated droplets can be inhaled by those in contact with the client, including visitors. These precautions should be followed even while changing sheets, since objects can be contaminated also. Option 2: Not this one. Measles, called rubeola, is another illness spread through droplet contamination. This client will also need airborne precautions to prevent staff or visitors from being infected or spreading this illness. Option 3: No! Impetigo is a skin infection caused either by staphylococcus, or streptococcus, and is highly contagious. The painful, itchy rash develops into large blisters which can leak or rupture, spreading bacteria. If this infection is not controlled by using contact precautions, it can develop into a more serious illness such as glomerulonephritis. While standard precautions always apply, additional contact precautions must be implemented, focusing on total PPE protection such as gowns and face shields. Option 4: Great! Pancreatitis is inflammation within the pancreas. Conditions that can lead to pancreatis include alcoholism and gallstones. Because this illness is restricted to the client, standard precautions are sufficient

Antepartum period

Conception until "true" labor begins

atelectasis

collapsed lung

Miosis

constricted pupils

Salmonella is a gram negative bacillus found in animal sources such as

chicken products, eggs, turkey, and some beef. Nausea, vomiting, and diarrhea after ingesting infected chicken would be the classic signs/symptoms

arterial problem

needs to be addressed immediately

skin grafts

warm that room up

somatoform disorders: major kinds

..., (also known as Briquet's syndrome) is characterized by physical symptoms that mimic disease or injury for which there is no identifiable physical cause or physical symptoms such as pain, nausea, depression, and dizziness. * Conversion disorder

The LPN is caring for a four month old infant diagnosed with respiratory syncytial virus (RSV) and placed in contact isolation. What personal protection equipment (PPEs) should the LPN use when providing care to the baby?

1. Double glove when changing the infant's soiled diapers. 2. Place face mask on infant when transported for x-rays. 3. Only gloves are necessary in order to provide infant care. 4. Wear gown and mask during feeding or burping of the baby. 4. /This question requires you to consider many different factors before choosing an appropriate option. Start with the basics, such as who is the client? Interestingly, the client in this scenario is actually the LPN and staff! The issue is to protect self, staff and other visitors from infection by observing the appropriate infection control protocols. The second consideration is to determine what type of isolation is needed for an infant with respiratory syncytial virus (RSV). You may recall the concern is oral, or respiratory secretions, yes? But go another step further and think about what type of PPEs would be appropriate for this isolation! Finally, consider how this LPN might come in contact with the infant's secretions. Once you get all these clues straight, read each option slowly to determine if those methods will protect everyone from RSV. Option 1: Wrong issue. This infant has RSV, which is contagious and spread through droplets or oral secretions. There are no enteric problems with the baby, and the virus is definitely not spread in stool or urine. Therefore, double gloving is not necessary for this client. Focus on the droplets! Option 2: No! Isolation does not mean it's okay to transport the client as long as they are covered with a mask! A client in isolation needs to remain in that room until the primary healthcare provider discharges the client to home, or out of isolation. X-rays must be taken in the isolation room with the required protective covers on the x-ray machine. Think about caring for a baby! Option 3: Definitely not! Always be suspicious when you see restrictive words, such as the word only. Isolation for RSV is contact precautions, with special focus on oral secretions. The question does not specify what is meant by providing care, but for an infant this age, it most likely involves feeding, bathing or changing diapers. Do you think the LPN's hands are the only areas that may come in contact with infant secretions? Option 4: Awesome! You remembered that little babies are messy eaters, sometimes drooling while drinking, or vomiting afterward, or even spitting up small amounts when burped. At four months of age, the LPN would be holding this baby during feeding and burping, potentially contaminating the LPN's uniform. When the LPN goes into another room, those droplets can spread the virus to other sick children. Therefore, it's important to use both gown and mask for protection when providing care to this infant.

A client diagnosed with rheumatoid arthritis has been prescribed dexamethasone orally as part of treatment therapy. What side effects should the nurse inform the client are expected?

1. Fatigue 2. Insomnia 3. Hypoglycemia 4. Truncal obesity 5. Increased appetite 6. Low blood pressure. These "select all that apply" questions can seem a bit intimidating at first, but the more you practice the basics, the better you will feel when faced with multiple options. Always start with the clues provided in the question. The client is being treated for RA, an auto-immune, inflammatory disease process which damages joints and organs in the body. Because there is no cure, the goal of treatment is to stop, or decrease, the inflammatory response in order to preserve joint and organ function while improving physical mobility. RA clients are treated with combinations of drug categories to achieve possible remission of the disease process. Some of these categories include NSAIDS, like ibuprophen or naproxen, disease modifying anti-rheumatic drugs (DMARDs) such as methotrexate, and short term corticosteroids like methylprednisolone (Medrol). The client in this question has been placed on dexamethasone (Decadron) which falls in the corticosteroid category. Recall what happens to the body when the adrenal glands are over producing glucocorticoids, as in Cushing's disease. The symptoms are the same when a client is taking corticosteroids, regardless of the reason. Steroids are prescribed when inflammation becomes very severe, and, because of the adverse side effects, the treatment is usually short term. But even over a period of a few weeks, the client can develop significant symptoms. Option 1: Good choice! There are many side effects from the use of steroids, and fatigue is one of the chief client complaints because interruption of sleep is common. Many things can contribute to a client's exhaustion, including not sleeping well, constant pain, and systemic response to an auto-immune process. Additionally, the use of steroids increases catabolism in the body, exacerbating all body responses and leaving the client very fatigued. Option 2: Absolutely. Steroids speed up normal body processes, including vital signs, appetite and gastric function. Additionally, corticosteroids wreak havoc on the adrenal glands, which you remember control the "fight and flight" response, making it very difficult for this client to relax and rest properly. The client may have great difficulty getting to sleep or staying asleep, creating an on going cycle of fatigue and even depression. This is why this medication is given early in the day or, in the case of multiple daily doses, the largest dose is given first thing in the morning. Option 3: Not this one. Did you notice it said "hypo", indicating low blood sugar? Recall that the action of excessive corticosteroids on the adrenal glands is the body's inability to regulate all that glucose, and therefore the client would become hyperglycemic. In addition to all the other problems caused by RA, think about what happens to the body when blood sugar is too high. Do you think the nurse might also reinforce client teaching on finger sticks for blood glucose monitoring? Consider all the ways the body could be adversely affected if blood sugar is not controlled. Option 4: Another good selection. Clients with RA will be prescribed systemic corticosteroids in some form intermittently for life, whenever the disease exacerbates. The drugs may be oral, injected, or even by infusion but the body's response is similar to Cushing's disease. Truncal obesity occurs because of redistribution of body fat while very thin extremities develop because of muscle wasting. This client might develop the buffalo hump as well if steroids are used long term. Option 5: Yes! When body processes are accelerated, whether by disease or medications, an increased appetite is the logical response. It is a complicated process, but the basic version is that the corticosteroids stimulate the release of amino acids and breakdown of fats. Remembering your nursing anatomy and physiology, and the gluconeogenesis process, the body's increase in blood sugar levels also increases the appetite for more sugar and starches. Option 6: Nope. We have been describing the acceleration of the body when given corticosteroids, so it is not logical to expect blood pressure to decrease. In fact, high blood pressure is often a problem for clients when taking these medications. Steroids influence the balance of water and sodium in the body, leading to fluid retention and even CHF. Don't forget this client will also be experiencing a weight gain, which will contribute to elevated blood pressure readings.

Which tasks could be completed only by the RN?

Admission assessments and teaching must be performed by the RN. The nursing process, along with teaching are outside the scope of practice of the LPN/VN. These are tasks that must be performed by the RN. The LPN/VN can reinforce teaching

Sign of infection

Hot spot

truncal obesity

Obesity which is more pronounced in the abdomen and is measured as a high waist-hip ratio

short of breath

high-Fowler's

The nurse receives report about a client who is termed "a drug seeker". The nurse giving report states that the client does not need the pain medication and is just asking for medication because the client is "hooked on it." After receiving report, what actions should the nurse take?

Monitor the client, Utilize a pain scale to determine level of pain, Back to the Basics here! Pain assessment is considered the fifth vital sign. And remember that pain is what the client says it is. Nurses should not be judgmental and stereotype clients based on the nurse's own beliefs. The nurse coming on duty must carefully monitor the client independently and without bias

A client asks a nurse to view his/her medical records. Which response by the nurse regarding this request is best?

You have the right to view your medical records and to have those records explained to you. Let's schedule a time to go over them. According to the Patient's Bill of Rights, the client has the right to view medical records and to have those records explained

respiratory acidosis

hypoventilation/hypertension and a decrease in level of consciousness

Epstein-Barr virus

infectious mononucleosis

Repiratory Alkalosis

lightheadedness, numbness and tingling, tinnitus and loss of consciousness

reposition client every two hours

Decreases potential skin breakdown

Beneficence

Doing good or causing good to be done; kindly action

primary prevention

Efforts to prevent an injury or illness from ever occurring.

A client diagnosed with hypothyroidism has received dietary education from the nurse. Which snack selection chosen by the client would indicate that education has been successful?

Popcorn / Hypothyroidism clients tend to have constipation due to decreased motility of the GI tract and need increased fiber and fluid intake. Popcorn is high in fiber

A client's Aunt calls the nurse's station to check on the status of her niece. What should the nurse do?

The aunt does not have authorization or a "need to know" about the client's condition and the nurse supervisor can not provide this information

infarction

sudden blockage of an artery

Only RN can:

(evaluate, assess, teach) administer blood initiate client referrals receive handoff client report initiate titrated dopamine drip based on hemodynamic values develop plan of care initiate feeding when risk of aspiration exists calculate and monitor TPN administration Give IV morphine care for cancer patients care for strict isolation patients

Which nursing actions are correct for a client in a Halo Traction?

1. Observe for signs of serous drainage. 2. Inspect skin under the halo vest. 3. Use sterile technique to clean pin sites. 4. Tape a torque screwdriver to the headboard. 5. Tighten a loose pin with a torque screwdriver . 2., 3. & 4. Correct: Inspecting the skin under the halo vest is necessary to look for excessive perspiration, redness, skin blistering, especially over bony prominences. When cleaning halo pins, sterile technique should be used in an effort to prevent infection which could enter the bone. A torque screwdriver should be readily available in case the screws on the frame need to be tightened by the neurosurgeon.

Which actions decrease risk of infection or damage to delicate tissue when the nurse is changing a wound dressing?

1. Warm cleansing solutions to body temperature. 2. Clean the wound when there is drainage present. 3. Use cotton balls to clean the suture site. 4. Use sterile gauze squares to dry the wound before applying the dressing. 5. Use sterile forceps when cleaning the wound. 1., 2. & 5. Correct: Using cleansing solutions at body temperature enhances the healing process by not lowering the temperature of the wound. Drainage should be removed so that it does not become the focus for infection. Sterile forceps should be used so that contaminated hands/gloves do not increase the risk of infection at the wound site. 3. Incorrect: Cotton balls may leave small cotton filaments behind that may serve as a site for infection. 4. Incorrect: Moisture is important for the healing process.

A client, who has been receiving enteral tube feedings for the past three days, has begun having diarrhea. Which interventions should the nurse employ?

2. Auscultate for hyperactive bowel sounds. 3. Monitor intake and output. 4. Check for fecal impaction. 5. Keep perianal area clean and dry.

A client asks to view their medical records. Which response made by the nurse is most appropriate?

According to the Patient's Bill of Rights, the client has the right to view medical records pertaining to the client's care and to have those records explained if necessary.

Dexamethasone

Corticosteroid

septic shock

Decreased blood pressure

When collecting data for the development of an infection following the application of a plaster cast to the leg, the nurse should reinforcing teaching to the client to observe for the presence of which sign of infection?

Hot spots is the best answer. Redness and increased warmth are indicators of localized infection. If the cast covers the extremity, redness cannot be visualized, but the client can feel more warmth (a "hot spot") in an area becoming infected

The typical abnormalities associated with bulimia are

Muscle cramps, Tingling of lips, Constipation and arrhythmias are all symptoms of this electrolyte and acid-base imbalance. Hypokalemia leads to metabolic alkalosis

A nurse is caring for clients when a new admit arrives on the unit. What action by the nurse is most appropriate?

Request a nurse on the floor to initiate the assessment process / The nurse is the only one who can assess.

gastric reflux

Reverse Trendelenburg

fecal impaction

Constipation

Which symptom identified in a client diagnosed with Guillain-Barre Syndrome would indicate that the nurse needs to notify the primary healthcare provider?

Breathlessness while talking indicates respiratory fatigue. Preparation for intubation needs to be made

Nonmaleficence (definition)

No harm is done when applying standards of care

A client is admitted to the LDR from the emergency department at 34 weeks gestation with profuse, painless, bright red vaginal bleeding. The priority action by the nurse is to prepare for which procedure?

Ultrasound exam/Painless, bright red vaginal bleeding is a sign of a placenta previa. Ultrasound can confirm this diagnosis with minimal risk to the mother and her fetus. This is the safest action for this client and best for fixing the problem

A nurse wants to find out a better way to perform oral care on unresponsive clients. What is the best action for the nurse to take in order to achieve this goal?

Discuss the issue with the leader of the "best practices" committee

Which task would be most appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)?

Taking vital signs on a client 12 hours postpartum. Taking vital signs is within the scope of practice for the UAP, but the nurse is responsible for evaluating the vital signs

eczema

redness of the skin caused by swelling of the capillaries

Which clients would be appropriate for the LPN/VN to be assigned by the charge nurse?

1. Client admitted with exacerbation of asthma. 2. Client needing oral antibiotics for a diagnosis of gastroenteritis. 3. Client 4 hours post lobectomy. 4. Client with terminal cancer refusing pain medication. 5. Client with arthritis who needs scheduled pain medication around the clock. 6. Client who has a chronic graft versus host disease. 2., 5, & 6. Correct. The LPN scope of practice includes caring for clients with chronic and stable health problems. These clients are stable. 1. Incorrect. The LPN should not care for an unstable client. This client is having an exacerbation of asthma which would make the client unstable and require ongoing assessment, evaluation and teaching. 3. Incorrect. This client is unstable and requires ongoing assessment, evaluation and teaching. A lobectomy is removal of part of the lung which is a complicated procedure. This is not a client who had a routine surgery which the LPN could care for. 4. Incorrect. This client is unstable and requires ongoing assessment, evaluation and teaching.

A medical-surgical nurse cares for a postoperative client who has undergone a percutaneous endoscopic gastrostomy (PEG). With which interdisciplinary team member is the nurse most likely to collaborate?

Nutritionist

Peak blood level

The maximum level that a drug reaches in the blood stream after it has been administered.

The nurse is caring for a client following gastric bypass surgery. The client reports dizziness, sweating and palpitations after eating meals. The nurse would recommend which actions to alleviate these symptoms

The symptoms described indicate the client is experiencing dumping syndrome, an adverse response following gastric or bariatric surgery. Clients may also experience tachycardia, nausea or cramping with the intake of food due to surgical restructuring of the gastrointestinal tract. Because this will be a lifetime issue, the nurse must teach the client to adjust eating habits and patterns. Reduction of carbohydrates will help decrease the problem since carbohydrates speed through the digestive track too quickly. Eating smaller, more frequent meals in a semi-recumbent position will further slow food through the digestive tract and eliminate most of the uncomfortable symptoms.

Guillain-Barre syndrome

This client is at risk for respiratory paralysis as the disease progresses. An emergency tracheostomy may need to be performed so the nurse should watch out for imminent signs of respiratory failure. Signs include heart rate that is more than 120 bpm or lower than 70 bpm and respiratory rate of more than 30 bpm. The nurse should monitor for signs of respiratory distress and prepare for intubation if needed.

The BRAT diet is recommended for clients with persistent diarrhea

This diet consists of bananas, rice, applesauce,and toast

If you are constipated

eat breakfast, If you think a certain food is a problem, try cutting it out of your diet for about 12 weeks,avoid caffeine

Metabolic Acidosis

headache, confusion, increased respiratory rate and depth drowsiness and nausea and vomiting

K-Pad

heating pad using hot water to provide heat, there are a variety of pad sizes

Which action by an unlicensed nursing assistant would require the nurse to intervene?

Turning off continuous tube feeding to reposition a client, then turning the feeding back on / The unlicensed nursing assistant should not turn tube feedings off or on. The nurse should do this when repositioning is needed. Prior to turning feeding back on, tube placement needs to be verified

IVPB (intravenous piggyback)

a small volume parenteral that will be added into or "piggybacked" into a large volume parenteral (LVP)

While a nurse was in shift report, four clients called the nurses' station. Which client should the nurse see first?

1. Child whose colostomy bag is leaking. 2. Three day post op client requesting pain medication. 3. Child admitted with failure to thrive, whose mother requested formula. 4. Client who needs a peak blood level drawn because the antibiotic just finished infusing. 4. Correct: The most urgent task is the peak medication level that needs to be drawn. If the level is not drawn at the appropriate time, the results may not give an accurate report of whether the medication is at the appropriate dosage or not, and if the dosage is safe. 1. Incorrect: A leaking colostomy bag is uncomfortable and should be seen, but this is not time sensitive like the peak blood level. 2. Incorrect: Pain needs assessing and treated appropriately. The key here is three days post op so the administration of the pain medication does not take priority over the need to draw the blood levels at this time. 3. Incorrect: Nutrition for a baby that is admitted for failure to thrive is important, but can wait a few minutes until blood levels are drawn.

A client has been admitted with a diagnosis of septic shock and has been successfully intubated. Which information requires the most immediate action by the nurse?

1. Lung assessment finding. 2. Blood pressure reading. 3. Elevated temperature. 4. Urine description and output. Septic shock involves persistent hypotension. The low blood pressure indicates that systemic tissue perfusion will not be adequate. This decreased perfusion will result in dysfunction and sometimes failure of one or more organs, such as the kidneys, heart, brain, liver and lungs. The blood pressure needs to be improved rapidly. This will be accomplished using IV fluids and sometimes vasopressors

When using crutches, the client's elbows should be flexed at

30 degrees

highest risk for colon cancer?

Has a family history of colon polyps

A nurse from the Emergency Department (ED) calls the floor to ask about a client who was admitted from the neighborhood. What is the appropriate response by the ED nurse to the nurse's question?

Refrain from answering the question for the nurse. The nurse should not be worried about offending the other nurse. The client's rights to privacy are priority in this situation

Cholinergic Crisis

Remember DUMBELLS - Diarrhea and abdominal cramping, Urination increased, Miosis (pinpoint pupils), Bradycardia, Emesis (nausea and vomiting), Lacrimation, Lethargy, Salivation to help you remember these signs and symptoms.

Phenytoin causes gingival overgrowth, swelling and bleeding of the gums

This can make oral hygiene more difficult

The nurse is caring for a burn victim with a skin graft to the hand. The area is pale and mottled but has good capillary refill. What is the nurse's best action at this time?

Warm the room.

upper GI series (sometimes called a barium swallow test)

the client swallows barium contrast while x-rays are taken

tertiary prevention

-aims to prevent the long-term consequences of a chronic illness or disability and to support optimal functioning -examples: prevention of pressure ulcers as complication of a spinal cord injury; promoting independence for the client who has traumatic brain injury

The nurse suspects a client admitted with myasthenia gravis is going into a cholinergic crisis. Which signs and symptoms would validate the nurse's suspicions?

1. Abdominal cramping 2. Lethargy 3. Salivation 4. Hypertension 5. Lacrimation 6. Miosis. / 1., 2., 3., 5., & 6. Correct: The signs of cholinergic crisis include Diarrhea and abdominal cramping, Urination increased, Miosis (pinpoint pupils), Bradycardia, Emesis (nausea and vomiting), Lacrimation, Lethargy, Salivation. Remember this: DUMBELLS as a mnemonic to help you recall these signs and symptoms.

The nurse in a psychiatric facility is assigning morning tasks to an unlicensed assistive personnel (UAP). What task should the nurse instruct the UAP to complete first?

1. Accompany client off unit to smoking area. 2. Obtain a morning weight on anorexic client. 3. Assist a client who is depressed to get out of bed. 4. Prepare the day room for group breakfast. The nurse is not only assigning tasks to the unlicensed assistive personnel (UAP), but is also providing specific instruction on which task must be completed first. This indicates the need for prioritization in the timing of task completion. Start by thinking about morning responsibilities in general. Nurses and UAP's help clients get up and dressed, assist with breakfast, and at certain in-patient care facilities, may monitor special activities such as smoking. Think about duties that assistive personnel can do even before breakfast, then look at the options. Option 1: There is a fine line between client rights and safety issues in any facility, which is why a staff member must always accompany a client smoker. Some facilities use a special smokers' cloth, placed across the client's chest and lap, to prevent client injury from dropped ashes, and only one or two cigarettes can be provided at a time. A client may request an early morning cigarette, even before breakfast, and an effort is made by staff to comply. However, another assigned task takes priority. Option 2: Excellent! Morning weights are always important and must be completed before breakfast. However, this is even more vital for an anorexic client whose weight variations are measured in tiny amounts. An accurate weight is obtained at the same time on the same scale in the same clothes every day and generally after an early morning voiding, prior to breakfast. Of all the tasks assigned by the nurse, this one takes less time but is most crucial. Option 3: Severely depressed clients generally do not participate willingly in daily activities, and often can't even get out of bed without assistance or encouragement. This client will obviously need help to get up and dress prior to breakfast. However, that will be time consuming while there is another task the UAP needs to complete first. Option 4: Group activities, including breakfast, are considered therapeutic in a psychiatric setting. Most facilities have a common room that is utilized for meals, craft activities or socializing. Therefore, preparing that location for clients and the delivery of meals is always important early in the day. This will most likely be time-consuming and although it must be done early in the day shift, there is another task the UAP needs to focus on first.

An unlicensed assistive personnel (UAP) reports to the charge nurse that a postoperative client's 8AM blood pressure is 200/104 and the oxygen saturation reading is 86%. What actions would be appropriate for the charge nurse to delegate?

1. Tell the LPN to assess for shortness of breath and evidence of tissue prefusion. 2. Have the LPN reinforce the use of relaxation techniques. 3. Ask the LPN to draw arterial blood gas levels. 4. Instruct the LPN to administer the prescribed dose of labetalol hydrochloride IM. 5. Instruct the UAP to call the primary healthcare provider and notify of change in client's condition. In this question the charge nurse is delegating tasks to someone else. It is a general question but does not specify who to delegate to. So look at each option alone as a true or false statement. Remember that the RN is responsible for assessment, evaluation, planning care, and teaching. Knowing that, let's look at the options. What option can you immediately eliminate? Option 1 because we know the LPN cannot assess. Look at option 2. This options asks the LPN to reinforce use of relaxation techniques. Can the LPN reinforce teaching? Yes they can. So this is true. Option 3. Can the LPN draw arterial blood gasses? No, this is beyond the scope of the PN. Sticking the artery is a high risk procedure. Option 4 Can an LPN give IM labetalol (a beta blocker)? Yes Option 5. Can the UAP call the primary healthcare provider? No, this is beyond the scope of the UAPs practice

A nurse educator is providing an inservice regarding the Health Insurance Portability and Accountability Act (HIPAA). When explaining this federal act, which provisions should the educator include?

2. Health care agencies must keep a client's personal health information confidential. 3. Clients have the right to request a copy of their personal health information. 4. A client's personal health information may be released to obtain health insurance benefits for the client. HIPAA is federal legislation enacted to protect a client's health information and privacy. Client identifiers and client health information should be kept strictly confidential. Clients have the right to request a copy of their personal health information. A client's personal health information may be released to obtain insurance benefits for the client

An 18 year old football player is admitted to the ortho unit after a femur fracture. He is scheduled for a rod to be placed in the morning, but suddenly develops severe shortness of breath, a petechial rash on his chest, and unstable vital signs. What should the nurse do first?

Call the active response team./ The client is exhibiting symptoms of a fat embolism, particularly with the petechial rash on his chest and severe shortness of breath. Due to his age, high risk behaviors with contact sports, and the large long bone fracture, he is the classic example of a client that may experience a fat embolus. This constitutes a medical emergency and activation of the response team

What is the nurse's most important role in the care of the family when a client's death is imminent?

Communicating news of the client's impending death to the family while they are together.

A school-age child is being discharged following treatment for sickle cell crisis. The LPN is reviewing instructions regarding homecare. What statement by the mother alerts the LPN the instruction was successful?

Daily hydration is vital to help decrease blood viscosity, which can decrease the frequency of crises. It is always easier to prevent problems than to treat the effects. Most sickle cell complications are the result of vaso-occlusions because of blood stasis in the vascular spaces. Increasing fluids as much as 8 to 10 glasses per day can keep blood flowing throughout the body and decrease likelihood of ischemia.

A client with an automated internal cardiac defibrillator (AICD) was successfully defibrillated. The telemetry technician shouts out that the client was in ventricular fibrillation (VF). What should the nurse do first?

Go to the client to collect data for signs and symptoms of decreased cardiac output / The client comes first. Check to see how they are doing by collecting data related to cardiac output. Make sure to include LOC, vital signs, skin and urinary output

Prior to signing a consent form for surgery, the client states "I am not sure that I understand the possible risks for this surgery and alternative treatments." What should the nurse do first?

Inform the primary healthcare provider that the client has concerns about the surgery

Following a motor vehicle accident, a client is brought to the emergency room with shallow, labored respirations. The client is intubated and placed on a ventilator. What is the nurse's priority action immediately after the intubation?

Listen for bilateral breath sounds

A client, admitted to the medical unit with persistent vomiting, reports weakness and leg cramps. The spouse states that the client is irritable. The primary healthcare provider has prescribed lab work and blood gases. Based on this data, the nurse anticipates which acid/base imbalance?

Metabolic alkalosis / Symptoms of alkalosis are often due to associated potassium loss and may include irritability, weakness, and cramping. Excessive vomiting eliminates gastric acid and potassium, leading to metabolic alkalosis.

Cellulitis treatment

Mild or early infections may be treated with oral penicillinase-resistant penicillin such as dicloxacillin or a cephalosporin. Erythromycin can be used if patient is allergic to penicillins. Severe infections, IV first generation cephalosporins. Can switch to oral therapy when fever, chills, and malaise subside. Mark margins of involvement before treatment to monitor progression or regression. If poor response to antimicrobial therapy or a necrotizing soft-tissue infection is suspected, surgical intervention is mandatory.

A client with an acute exacerbation of systemic lupus erythematosus (SLE) is hospitalized with incapacitating fatigue and fever. A urinalysis reveals proteinuria and hematuria. The primary healthcare provider prescribes corticosteroids. During the acute phase of the client's illness, what is most important for the nurse to do?

Monitor intake and output and daily weight.

factors for stress urinary incontinence should a nurse collect data for in an elderly female

Multiparous vaginal births, Rising abdominal pressure, Lack of estrogen

The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). Which action should the nurse interrupt the UAP from performing?

Placing the traction weights on the bed to transfer the client to x-ray 3. Correct: Traction should never be relieved without a primary healthcare provider's prescription. It can result in muscle spasm and tissue damage. This client could be transferred with traction still maintained. 1. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. 2. Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. Each ROM movement should be repeated 5 times during the session. 4. Incorrect: The first void of a 24 hour urine is discarded and can be delegated to the UAP. The nurse would then start the 24 hour urine once the 1st void has been discarded. The nurse also needs to be aware of the color and amount of urine voided.

The nurse is reinforcing instructions to a client with chronic obstructive pulmonary disease (COPD) about nutrition and maintaining body weight. Which information is most important for this client?

Plan rest periods before and after meals / Even more important than what the client eats is whether the client is able to complete the meal. Dyspnea and exhaustion often prevent a COPD client from consuming enough calories or nutritious foods to maintain normal body weight. Just preparing the food can tire the client too much to eat anything. Resting just before and immediately after for at least 30 min

A client has returned to the room following a liver biopsy. The nurse is aware what position is best for the client?

Right side for at least two hours

Which male client condition in the after-hours clinic should the nurse see first?

Scrotal pain and edema. This client is likely to have testicular torsion, which requires immediate intervention. Infarction of the testes can occur if not treated promptly

skin of a client diagnosed with diabetes

Small abrasion on great toe

Which healthcare provider would be considered a case manager?

Social worker, Nurse

After discontinuing a peripheral IV line, it is most important for the nurse to record which information?

The length and intactness of the catheter tip./ This is the most important information that needs to be documented. This information would be important in determining if a potential safety issue/complication could occur as a result of the IV line being removed or a portion of the catheter tip breaking off before removal

A client at a rehabilitation facility states, "No one asked me which rehabilitation facility I preferred. I feel as if this entire process took place without my involvement. I was not informed of alternative options." Which client right is being violated?

The right to participate in the plan of care

A client is being transported to radiology from an inpatient nursing unit. The unlicensed assistive personnel (UAP) and a family member accompany the client to radiology. To whom should a nurse assign responsibility for the client's medical record during transport?

The unlicensed assistive personnel (UAP)

A pregnant teenage client says, "I am not sure that I want to have this baby. What do you think about an abortion?" What should the nurse say?

What are your thoughts about abortion?

pernicious anemia

Without enough vitamin B-12, the body will produce abnormally large red blood cells called macrocytes. Because of their large size, these abnormal cells may not be able to leave the bone marrow, where red blood cells are made, and enter the bloodstream. This decreases the amount of oxygen carrying red blood cells in the bloodstream and can lead to fatigue and weakness Vitamin B12, a nutrient needed to prevent pernicious anemia, is found in some foods like meat, fish, eggs, and milk.

Post Percutaneous Transluminal Coronary Angioplasty (PTCA)

is a minimally invasive procedure to open up blocked coronary arteries, allowing blood to circulate unobstructed to the heart muscle. ... Next, a long narrow tube called a diagnostic catheter is advanced through the introducer over the guide wire, into the blood vessel

low residue foods

oatmeal or pasta are both good choices as well as fruits with no skin and little pulp Cantaloupe Clients also need to avoid most fresh fruits with skin, pulp, or seeds

Jackson-Pratt drain

the bulb must be emptied at only 2/3 capacity

maintain normal voiding habits while recovering from a cesarean section

push over the pubic area with hands, read or listen to music, warm water over the perineum

veracity

truthfulness, honesty

A client who only speaks Spanish is admitted to the surgical unit. What is the best method for the nurse to reinforce with the client about a pre-surgical procedure?

Use an audiotape made in Spanish to inform the client of the pre-surgical procedure

After giving an injection to a client, the nurse is stuck by the used needle. What should the nurse do first?

Wash the wound with soap and water

A nurse is calling the primary healthcare provider about a client who is experiencing a migraine. Which statements by the nurse are appropriate according to the communication tool SBAR (Situation, Background, Assessment and Recommendation)?

1. "Hello Dr, I am calling about one of your clients." 2. "Jane Doe is reporting a migraine." 3. "Jane Doe was admitted two days ago. Pulse is 92, BP 152/80, Resp 22." 4. "From my data collection, she states she has a hx of migraines and is prescribed sumatriptan for relief." 5. "I recommend that she recieve a dose of sumatripten. Do you agree?" 2., 3., 4., & 5. Correct: First, the nurse should identify self, agency, and client calling about. Then deliver SBAR. The Situation, Background, Assessment and Recommendation (SBAR) technique has become the Joint Commission's stated industry best practice for standardized communication in healthcare, effortlessly structuring critical information primarily for spoken delivery. Each of these statements fulfills appropriate SBAR requirements. 1. Incorrect. The nurse should identify the primary healthcare provider by name and should then identify self, the agency the nurse is calling from and the client by name. For instance: "Dr. Smith, this is nurse Adams, RN. I am calling about your client, Jane Doe, at ABC hospital."

An LPN is providing care for a post-Cesarean section client with a history of cardiac disease. When reviewing home dietary plans, the LPN realizes further instruction is needed when the client makes what statement?

1. "I should eat extra fiber to prevent constipation." 2. "I must drink lots of fluid to increase breast milk." 3. "I will check my weight and record it every day." 4. "I need to rest frequently throughout the day/Always start by analyzing what clues are provided in the question! You see this client has a history of heart disease and has delivered an infant by Cesarean section. Recall that pregnant clients with pre-existing heart disease have many additional problems to consider, especially following the birth. Increased fluid volume during pregnancy places the client at risk for congestive heart failure (CHF). Additionally, a Cesarean section actually places the client at an even higher risk for complications. It is vital for this client to understand specific instructions to follow after discharge. The second important factor to note is the LPN realizes the client needs further teaching, which means you are looking for a client statement that is incorrect! Even though this is not a "select all that apply", you should use the same true/false process with each option. As you read each option, ask yourself if the comment is accurate or incorrect. Remember - you are looking for an incorrect statement by the client! Option 1: Not what you are looking for! This client comment is true. Fiber is healthy for post partum clients to prevent constipation, but especially for those with heart disease. Constipation causes an increased workload on an already weakened heart, potentially leading to more complications. Try another option. Option 2: Excellent choice! You are looking for a false statement, and you found it! While most new mothers are instructed to stay well hydrated for breast feeding, extra fluid is dangerous for a client with known cardiac disease. The client's heart is already overwhelmed from the pregnancy and then the Cesarean section. What this client needs is rest, reevaluation by the cardiologist, and proper diet. Obviously the LPN recognizes the teaching needs reinforced with this client. Option 3: Definitely not. Recall that you are looking for a false statement from the client; however, this comment is accurate. Any client with existing cardiac disease is aware that among the earliest indications of heart failure would be a 2 or 3 pound increase in body weight overnight. This client is aware a daily weight is crucial to detect early complications, indicating successful teaching. Try again. Option 4: Wrong choice. You are searching for an incorrect client comment, but this statement is accurate. Pregnant females need to rest often, particularly those with pre-existing cardiac disease. After delivery, as the heart recovers from the strain of the pregnancy, delivery and increased fluid volume, rest is even more crucial for this new mother. This client will also be dealing with the responsibilities of a newborn. This comment by the client indicates that teaching was very successful. Remember you are looking for a false statement.

A nurse in a long-term care facility is reinforcing teaching to newly-unlicensed assistive personnel (UAP) about advance directives. Which statements by the nurse regarding a Health Care Power of Attorney are correct?

1. "The Health Care Power of Attorney identifies the person designated to make end-of-life care decisions on a client's behalf." 2. "The Health Care Power of Attorney identifies the health care providers that are permitted to care for the client." 3. "The Health Care Power of Attorney identifies the person designated to make financial decisions for the client if the client is incapacitated." 4. "The Health Care Power of Attorney identifies the person designated to make health care decisions for the client if the client is incapacitated." 5. "The Health Care Power of Attorney identifies the person designated to make funeral arrangements for the client if the client dies." 1. & 4. Correct: The purpose of the Health Care Power of Attorney is to identify the person designated by the client to make end-of-life decisions on the client's behalf. The purpose of the Health Care Power of Attorney is to identify the person designated to make health care decisions for the client if the client is incapacitated. 2. Incorrect: The Health Care Power of Attorney does not identify which health care providers may care for a client. 3. Incorrect: A Power of Attorney allows a designated person to act on the client's behalf with regard to financial matters whereas a Health Care Power of Attorney allows a designated person to act on the client's behalf with regard to medical decisions only. 5. Incorrect: The Health Care Power of Attorney does not identify the person designated to make funeral arrangements for the client if the client dies. This person would most likely be identified in the client's last will and testament.

The LPN/VN could safely accept which client assignments?

1. A client two days post appendectomy needing to ambulate. 2. A client with bronchitis receiving nebulizer treatments. 3. A newly diagnosed diabetic client awaiting discharge home. 4. A client newly admitted with exacerbation of myasthenia gravis. 5. A client admitted yesterday for observation following a fall. 6. A client with a nasogastric tube (NG) hooked to low suction. Wow! This may seem overwhelming at first glance! But with any 'select-all-that-apply', you must look at each option individually as though it were a true/false response. This question is asking which clients would be appropriate for an LPN/VN, so consider what you know about the LPN/VN scope of practice. An LPN/VN cannot assess, evaluate, create a plan of care, or do initial teaching. An LPN/VN can "re-evaluate" teaching to see if the client understands, but cannot initiate new instruction. Another important aspect to remember is that you cannot "assume" information that is not specifically provided in the question. Option 1: Yes, this is a great assignment for an LPN/VN, even though it does not specifically state whether the client had an open or closed (laparoscopic) appendectomy. That is because it does not matter overall - the client needs to ambulate, which is within the scope of practice of the LPN/VN. In fact, ambulating this client could easily be delegated by the LPN/VN to a UAP. Option 2: This is a stable client with a chronic illness (bronchitis) who will require a respiratory assessment at some point during the shift; however, the LPN/VN can provide nebulizer treatments and take vital signs during the shift, both of which are within the LPN/VN scope of practice. Option 3: Definitely not! The client is a new diabetic, indicating a lot of teaching will be involved. You also know that discharges involve teaching, but this question does not indicate if teaching has yet been initiated. You cannot assume what may or may not have been done when it has not been specified; however, we DO know that an LPN/VN cannot initiate discharge teaching. Option 4: Myasthenia gravis is an autoimmune disorder in which the neuromuscular system becomes progressively weaker, even throughout the day. As a new admission, this client would not be appropriate for an LPN/VN, who cannot be assigned admissions, discharges, or transfers. Additionally, this client will need frequent assessments throughout the day to monitor for respiratory distress from muscle weakness. Option 5: Another good choice! When a client is admitted for "observation", that indicates the client is not quite serious enough to actually be an "in-patient", but is also not stable enough to just send home. Most facilities consider "observation" to be a 24 hour period in which the client's condition is closely monitored for any unforeseen complications prior sending the client home. Option 6: True. The PN can monitor placement, patency and correct position of the NG tube.

Which client is legally able to sign a consent for surgery?

1. An 86 year old client who is disoriented. 2. A 62 year old client who speaks only Spanish. 3. A 41 year old client who just received midazolam. 4. A 17 year old client needing an emergency appendectomy whose parents cannot be contacted. 5. A 44 year old with schizophrenia who is hallucinating. 2., & 4. Correct: The Spanish speaking client should have a trained medical interpreter, either in person,by telephone, or by video conference, but the client can still sign the consent. Using an interpreter, such as a family member or friend, who is not a trained medical interpreter should be avoided unless absolutely necessary because the translation may not be accurate. The 17 year old client is considered a minor and cannot provide legal consent if a parent or legal guardian is present or readily available. However, since the parents are not available, the emergency exception rule, known as "implied consent" would be followed in which there is an assumption that, if present, the legal guardian would consent to the emergency treatment of the minor. The primary healthcare provider must document the nature of the emergency, the reason why immediate treatment is required, and the attempts to obtain consent from the minors parents or legal guardian. 1. Incorrect: The 86 year old client who is disoriented is not considered capable of making an informed decision. In order for consent to be legally valid, the client must be considered competent to make the decision and the consent must be voluntary. In determining if the client is capable to make the decision, the client must be able to understand the situation, understand potential risks associated with the decision, and be able to communicate a decision based on the understanding of the information provided. 3. Incorrect: Midazolam is a benzodiazepine administered for preoperative sedation/amnesia. For a consent to be legally valid, the consent must be signed prior to being administered preoperative medication or other mind-altering medications. 5. Incorrect: This client with schizophrenia who is hallucinating does not have the ability at this time to understand explanations, understand risks and benefits, and communicate a decision based on that understanding. Therefore, this client cannot make a legal informed consent. There may be times that this client is lucid and considered competent, but the hallucinations are interfering with this now.

What interventions should the LPN/VN include when reinforcing teaching with a client on how to prevent and treat fungal infections of the feet?

1. Apply cornstarch to the feet after bathing. 2. Put terbinafine hydrochloride cream 1% on affected areas twice a day for two weeks. 3. Wear socks at all times until infection has cleared up. 4. Wash feet daily with soap and water. 5. Wear shower sandals when showering in public places. 6. Wear shoes that allow the feet to breathe. Before we review the options, let's look at the question. The key words in a question should be identified. The key words in this question are teach,prevent,treat fungal infections,and feet . Each option stands alone with the question. After reviewing the question, look at each option and identify if it is true or false. This question is asking about preventing and treating fungal infections. So let's look at the options. Option 1 is false. Clients with fungal skin infections should avoid the use of cornstarch. The carbohydrates in cornstarch may provide nutrition to fungal infections and should be avoided. The client can apply a powder specifically for feet is approved. Option 2 is true. Terbinafine hydrochloride cream 1%, an topical antifungal, is prescribed for the treatment of fungal infections of the feet. Option 3 is false. Allow feet to have exposure to the air. The feet must be kept clean and dry since fungus thrives in moist environments. Keeping the feet covered all the time causes a dark, moist environment for the fungus to thrive. Option 4 is true. The feet must be washed daily with soap and water and dried thoroughly since the fungus thrives in moist environments. Option 5 is true. Steps to prevent athlete's feet include wearing shower sandals in public showering areas. The showers in public areas may continue to stay moist after someone has showered. A moist floor is a good medium for the growth of fungus. Also other people who showered may currently have a fungal infection on their feet. Option 6 is true. Wearing shoes that allow the feet to "breathe" will decrease the feet from perspiring. Moisture on the sole of the feet and between the toes is a good medium for the growth of fungus.

Which tasks can the LPN/VN complete when assisting with the care of a client scheduled for an adrenalectomy?

1. Check finger stick glucose level. 2. Administer regular insulin SQ based on sliding scale prescription. 3. Assess client's cardiac rhythm. 4. Reinforce teaching regarding postoperative care. 5. Review client's pre-surgical laboratory values. 1., 2., & 4. Correct: The LPN/VN can perform these tasks and can reinforce teaching. 3. Incorrect: The RN must assess, evaluate, and teach. The LPN/VN can collect data to assist the RN, but the RN must validate that the data is correct. 5. Incorrect: The RN must assess, evaluate, and teach. The LPN/VN can collect data to assist the RN, but the RN must validate that the data is correct.

A nurse in the nursing home has several issues regarding staff maintaining proper infection control while caring for clients. What actions should the nurse take regarding this issue?

1. Place colorful posters regarding infection control in conspicuous places on unit. 2. Monitor staff providing client care for the use of appropriate infection control. 3. Give staff written information on proper infection control. 4. Have all staff read agency policy and procedures regarding infection control. 5. Dock pay of staff who do not maintain proper infection control. 6. Inform staff of in-service sessions on infection control for every shift. 1., 2., 3., 4., & 6. Correct. Each of these actions can be taken by the LPN/VN. The staff needs further information, reminders, and follow-up observation. 5. Incorrect. This is not the best solution. Most people want to do what is right. Education should be tried first, then documentation of infractions.

The charge nurse is reviewing the plan of care for a client during the first day post-craniotomy. Which nursing actions can an experienced LPN/LVN working in the ICU accept from the charge nurse?

1. Determine Glasgow Coma Score. 2. Check endotracheal tube (ET) cuff pressure every shift. 3. Reposition client from side to side every 2 hours. 4. Administer acetaminophen via nasogastric tube for temperature greater than 101ºF (38.3ºC). 5. Monitor intake and output every hour. 4., & 5. Correct: Both of these actions are within the scope of practice for the LPN/LVN. 1. Incorrect: Assessing the Glasgow Coma Score should be done by the RN. 2. Incorrect: ET tube cuff assessment is accomplished by an experienced RN. 3. Incorrect: Usually, repositioning a client would be within the scope of practice for the LPN/LVN; however, this client is at risk for increased ICP during position changes. The RN must monitor.

What information should be reinforced when a LPN/VN is talking with a group of college students about the transmission of hepatitis B and human immunodeficiency virus (HIV)?

1. HIV is transmitted via toilet seats whereas hepatitis B is not. 2. HIV is transmitted by sexual contact whereas hepatitis B is not. 3. Hepatitis B is more readily transmitted via needle sticks than HIV. 4. Neither virus is transmitted via body fluids. Look at options 2 and 4. Option 2 says that HIV is transmitted by sexual contact, but option 4 says that neither virus is transmitted by body fluids. So one of these options must be wrong. If you know that at least one or both of these diseases is transmitted via body fluid then you can automatically eliminate option 4. Look at option 2 now. We know that HIV is transmitted sexually. That's true. But what about Hepatitis B? It is also transmitted sexually, so option 2 is wrong. Look at option 1. Both of these disease will not live outside of body fluid, so cannot live on a clean toilet seat. Keep in mind that dried blood can have the disease, however. That leaves option 3. Even if you did not know that Hepatitis B is more readily transmitted via needle sticks than HIV, you should be able to easily eliminate the other options.

A primary healthcare provider prescribes contact precautions for a newly admitted client. What equipment does the nurse need to place outside of the client's room for use when entering the room?

1. Gown 2. Gloves 3. Goggles 4. Surgical mask 5. N95 respirator. 1 , 2., Before we review the options, let's look at the question. The key words in a question should be identified. The key words in this question are contact precautions, equipment, and entering room. Each option stands alone with the question. After reviewing the question, look at each option and identify if it is true or false. Remember client safety is always a priority. So let's look at the options. First, you must understand contact precautions. Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the client or the client's environment. Contact Precautions apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission. ​​ Option 1 is true. Contact precautions require the nurse to don a gown when entering the room of a client. Remove the gown when leaving the room, dispose of it in a waste container, and perform hand hygiene. This makes option 1 correct. Option 2 is true. Contact precautions require the nurse to don gloves when entering the room of a client since the environment surrounding the client may be contaminated as well as the client. Option 3 is false.This is false. Goggles are not required for contact precautions. Option 4 is false. This is also false. A surgical mask is not required for contact precautions. Option 5 is false. Special air handling and ventilation are not required to prevent contact transmission because infected secretions are not suspended in the air

The nurse is caring for a client diagnosed with major depression post electroconvulsive therapy (ECT). What nursing care should be included in this immediate post-treatment period?

1. Monitor vital signs every hour for eight hours. 2. Position the client on their side. 3. Stay with the client until fully awake. 4. Provide flexibility in scheduling routine activities. 5. Encourage the client to ambulate in room and hall. 2. & 3. Correct: Positioning on the side will prevent aspiration. Stay with the client until they are fully awake, oriented, and able to perform self-care activities without assistance. Safety is priority. 1. Incorrect: Pulse, respirations, and blood pressure should be monitored every 15 minutes for the first hour. Vital signs every hour are too long immediately post-treatment. 4. Incorrect: The client needs a highly structured schedule of routine activities in order to minimize confusion. Also, immediately post-treatment is too soon to address routine activities. 5. Incorrect: The client should remain in bed during the immediate post-treatment period. The client needs to be fully awake prior to ambulation

Which discussion points should a LPN/VN plan to reinforce when talking with a group of college students on prevention of sexually transmitted infections (STI)?

1. Safe sex practices 2. Routine human immunodeficiency virus (HIV) testing 3. Proper use of birth control pills 4. Sexual abstinence 5. Vaccinations for STIs. 1,4,5, /Before we review the options, let's look at the question. The key words in a question should be identified. The key words in this question are college students, prevention, and sexually transmitted infections (STI). Each option stands alone with the question. After reviewing the question, look at each option and identify if it is true or false. Remember client safety is always a priority. The question is asking for talking points to prevent STIs. So let's look at the options. Option 1 is true. Safe sex practices will include proper use of contraceptives, sexual attitudes, and sexual anatomy and physiology, Option 2 is false. Routine HIV testing is not a way to prevent HIV or other STIs. It will provide early diagnosis. The best course of action is to prevent occurrence. Option 3 is false. Birth control pills help prevent unplanned pregnancy. STIs can still be contracted if proper safe sex techniques are not implemented. Option 4 is true. Abstinence is the best way to prevent STIs. Option 5 is true. Vaccines are available for some STIs such as human papillomavirus vaccine (HPV)..

Which client should the nurse recognize as being at greatest risk for the development of cancer?

1. Smoker for 30 plus years 2. Body builder taking steroids and using tanning salons 3. Newborn with multiple birth defects 4. Older individual with acquired immunodeficiency syndrome. 4. Correct: Cancer has a high incidence in the immune deficiency client and in the older adult with both of these risk factors together, this one is the highest risk for cancer. 1. Incorrect: Although smoking is a known environmental carcinogen, this one risk factor alone is not the highest risk. 2. Incorrect: These are known environmental carcinogens, but do not rank as highly as aging and immune deficiency. 3. Incorrect: Birth defects are not a risk factor for cancer.

The nurse is working with a new unlicensed assistive personnel (UAP) on a postoperative floor. The first vital sign check on a new postoperative client was performed by the nurse. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. In planning care for the postoperative client, the nurse decided to retain the task of vital sign assessment. What was the rationale for this plan?

1. The nurse did not trust the new UAP. 2. The nurse prefers to check all vital signs on clients. 3. The nurse's role includes assessment of vital signs of post-op clients. 4. The nurse does not know the skills of the new UAP. 4. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. When the licensed person cannot do this, the task should not be delegated 1. Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the staff member. 2. Incorrect: When a floor is very busy, the nurse should rely on the UAP if the person is competent to perform the tasks. 3. Incorrect: The nurse can measure vital signs; however, agency policy usually states that the UAP can perform this task also.

Advance directives

A form of a living will. It specifies your wishes regarding healthcare and treatment options should you become incapacitated

Fiber

A form of complex carbohydrates from plants that humans cannot digest

Anyone who has had a stroke is at risk for

aspiration, especially with a history of reflux disease. It is important to remember that the stomach is full of acid. When aspiration of this acid occurs, it causes irritation to the lung tissue. The client can develop a severe pneumonitis. That's what could kill the client, so this answer takes priority

serous drainage

clear, watery plasma

A client with acquired immunodeficiency syndrome (AIDS) is admitted to an emergency department in respiratory arrest. There is no advanced directive in the client's medical record. Which action should a nurse take?

Activate the code protocol and resuscitate the client. The nurse should immediately resuscitate the client. Failure to resuscitate a client without a Do−Not−Resuscitate (DNR) order is considered negligence regardless of the client's diagnosis

Which suggestion should the nurse make to assist the client to boost the immune system?

Add lean protein to the diet/ Protein will help to improve the functioning of the immune system

The client complains of crushing substernal chest pain radiating down the left arm. Which measure should the nurse initiate first?

Administer oxygen at 2 L/nasal cannula / So what should the nurse be worried about? That the client is having an MI? Yes. A crushing substernal chest pain radiating down the left arm is classic for an MI. So what option can help the client? Oxygen administration to get more oxygen to the heart muscle

myasthenia gravis on pyridostigmine

client has not had any medication all night and is at great risk for muscle weakness in the morning, increasing the potential for aspiration at breakfast. This client is at the top of the priority list!

elderly client with dry skin

lotion, Fluids, Decreasing the frequency of bathing , Avoid using soap on the extremety dry areas.

amniocentesis

needle puncture of the amniotic sac to withdraw amniotic fluid for analysis

The nurse is working on a unit with several postoperative clients. While encouraging the clients to cough and deep breath, the nurse realizes that coughing poses the greatest risk to which client?

An elderly client who had cataract removal / Now you are thinking! This client is definitely at greatest risk from the standard nursing protocol for coughing and deep breathing. Eye surgery is very delicate, and the biggest concern is a possible increase to intraocular pressure. Following cataract surgery, the client will have tiny sutures to hold the new lens in place. Any action that increases that eye pressure can potentially damage the eye, the new lens, or the client. In addition to basic human functions such as sneezing, vomiting, bending over, or even straining, the nurse must be concerned that the client may develop postoperative complications such as atelectasis or pneumonia

purulent drainage

redness, and pain would indicate the likelihood of infection

The nurse reinforces instructions with a client about deep breathing and coughing exercises that will be performed postoperatively. Which statement by the client indicates that these instructions have been effective?

Coughing and deep breathing should be performed hourly to prevent pneumonia.

The nurse is performing sterile wound care for partial thickness burns on a client's lower right leg. Prior to initiating this procedure, what action should the nurse complete first?

Determine current pain level and medicate.

definitely wrong

Did you notice that this answer includes the word "only"? That word is another absolute word like "always", or "never". These words are like red flags of caution because absolutes are rarely accurate

A client's primary healthcare provider writes a prescription to "obtain consent for a bronchoscopy and possible lung biopsy." When the nurse presents the consent form to the client, the client states, "I don't know what a bronchoscopy is." Which is the best action by the nurse?

Immediately inform the primary healthcare provider that the client requests additional information related to the bronchoscopy procedure

An unlicensed assistive personal (UAP) has been floated to the emergency department (ED) because of several staff call offs. Since the UAP has never worked in the ED, what is the most appropriate task the nurse could assign?

Escort clients from the ED to other areas for tests Staff call offs are always a problem in any hospital department, but even more so in a busy emergency room. In fact, this is such a problem that, in this scenario, a UAP (unlicensed assistive person) who has never worked in the ED has been floated to that area to help replace absent staff. The nurse needs to find a suitable task for this UAP, without providing an appropriate orientation to that area. This is tricky, since the emergency room is a specialized area that entails a lot of unique situations and circumstances. You have a spare pair of hands but don't have the time to provide training and orientation - what do you do? This happens more often than you might imagine, and the most important thing to remember is client safety! How can you make the best use of float personnel, utilizing skills to the maximum, and keep the assigned duties within the training level of those personnel? This is the challenge! Option 1: Sounds very helpful, doesn't it? Wrong! Examination rooms are stocked with specific equipment and supplies to be used in a wide variety of urgent or critical situations. It is unreasonable to expect new float personnel to know how to properly prepare the diverse areas of the ED without the benefit of orientation to that department. More importantly, the life of clients arriving in the ED may depend on having the right equipment available and ready when an emergency requires it. It all comes down to client safety! Option 2: This might be a good idea when there are enough staff available, but that is not the case here! The reason this UAP was unexpectedly floated to the ED in the first place was because of too many employee call offs, leaving that area short staffed. So you have a UAP who has not had the benefit of an orientation, floated to a highly specialized area. It wastes of a spare pair of hands to have the UAP just follow around someone who had previously worked the ED. The nurse needs to get creative! What would be most helpful to the department without placing either the UAP, the nurse, or clients in jeopardy? Think again! Option 3: Again, a big no! Can you hear the charge nurse's comments? "Just sit there at the desk and stay out of trouble." That would totally defeat the need for additional staff personnel to assist in such a busy hospital department. Besides, the reception area is vital to the efficient operation of emergency care. This area is the initial contact with clients, including incoming phone calls. These personnel need to be trained in both interviewing techniques and assessing the need for immediate triage. Additionally, answering calls would require knowledge of appropriate HIPPA regulations and accepted responses to questions. There is more to this than realized! Try again. Option 4: A great choice! Clients in the ED are always coming and going, and quite often, that means to another department for tests. Remember that any client sent to another department generally is stable enough to leave the emergency exam room. That means the client can be escorted by non nursing personnel, such as volunteers or UAP. On other hospital floors, it is not unusual for UAP to frequently escort clients as part of normal daily routines. Therefore, this task would be something the UAP is familiar with and capable of safely completing.

Sitting up after a meal is counterproductive

since this will increase the speed of food through the digestive tract

The client is aware that the non-surgical "good" leg should be placed on the steps first when going upstairs

while the surgical "bad" leg is placed on the stairs first when coming down steps

A new mother asks the clinic nurse why her baby should receive recommended vaccinations. What is the best response by the nurse concerning vaccinations?

will help your baby produce antibodies against disease causing organisms

Which room assignment would be most therapeutic for the nurse to make for a client with bipolar disorder in manic phase who is hyperactive and has difficulty sleeping?

A private bedroom/A private room will help to decrease stimulation. The client with bipolar disorder needs a calm environment especially when in the manic phase. Avoid excessive stimulation.

The nurse is removing the client's peripheral IV line prior to discharge. The nurse completes the appropriate steps in what order?

Wash hands apply gloves clamp IV line closed securely ,stabilize cannula with one hand,loosen tape and tegaderm cover, apply gauze and tape tightly

Contraction Stress Test (CST)

Method for evaluating fetal status during the antepartum period by observing response of the fetal heart to the stress of uterine contractions that may induce recurrent episodes of fetal hypoxia.

Which ethical principle is involved in reporting a medication error to the primary healthcare provider?

Nonmaleficence is best illustrated with the nurse's action, as the goal is to do no harm to the client. With timely reporting of an error, further complications may be prevented.

A client with a deep partial-thickness burn to the right forearm has returned from surgery with a skin graft to the burned area. Which graft site intervention would the nurse implement within the first 24 hours?

Position arm to prevent pressure to the graft site. The arm should be situated so there is no compression on the graft site. Applying pressure to the graft may cause the graft to move which may result in damage to the graft site.

To reduce the risk of developing a hematoma post-balloon angioplasty, the nurse should implement which measure?

Prevent flexion of the affected leg.

A nurse is reinforcing teaching in a parenting class for first time parents in an attempt to decrease child abuse in the community. What type of prevention is the nurse utilizing?

Primary prevention / Primary prevention is aimed at reducing the incidence of mental disorders within the population. Primary prevention targets individuals and the environment. Emphasis: assisting individuals to increase their ability to cope effectively with stress and targeting and diminishing harmful forces (stressors) within the environment. Reinforcing teaching about parenting skills and child development to prospective new parents is primary prevention.

A nurse is caring for a client who was brought into the ED with a gunshot wound to the chest. There is an occlusive dressing in place and the client is receiving high flow oxygen. The nurse notes a deviated trachea, asymmetrical chest wall movement and decreased breath sounds bilaterally. What action should the nurse take first?

Remove the occlusive dressing, The client has developed a tension pneumothorax as evidenced by these signs/symptoms. This developed as a result of the placement of an occlusive dressing over the chest wound. By removing the occlusive dressing the pressure pushing to the opposite side of the chest should stop. Dressings over "sucking chest wounds" should be taped down on 3 sides only to allow air to escape but not re-enter. A needle decompression may be required as an emergency measure

PTCA (percutaneous transluminal coronary angioplasty)

Reporting any chest discomfort following percutaneous intervention, Avoid lifting more than 10 pounds until approved by healthcare provider

Five Rights of Delegation

The "right" person The "right" task The "right" circumstances The "right" directions and communication The "right" supervision and evaluation

The nurse is passing morning medication on a busy long-term care unit and has been delayed in completing rounds. When deciding how to distribute the remaining scheduled medications, which client would the nurse consider at greatest risk if medications are late?

The client with myasthenia gravis on pyridostigmine Now, this serious disorder actually impacts the client's ability to function throughout the day! Even if you did not remember pyridostigmine, you do know that clients with MG become weaker throughout the day, requiring doses of medication every 4-6 hours. Additionally, this client has not had any medication all night and is at great risk for muscle weakness in the morning, increasing the potential for aspiration at breakfast. This client is at the top of the priority list

A nurse is collecting data on a client who is reporting bone pain secondary to cancer with metastasis to the bone. What does the nurse determine is the most important information to gather at this time?

The client's description of the pain / The most important information to gather is the client's perception and description of the pain. Pain is subjective, based on the client's perception. This is also the primary complaint of the client at this time.

Which clients can the nurse assign to the same room?

1. A 48 year old female one day postoperative appendectomy and a 30 year old female with nephrolithiasis 2. A 41 year old male with nausea, vomiting, and diarrhea and a 62 year old male with neutropenia 3. A 41 year old male with Methicillin-resistant Staphylococcus aureus (MRSA) infection and a 42 year old male with Clostridium difficile 4. A 14 year old two days postoperative splenectomy and an 80 year old female with Parkinson's disease 5. A 57 year old female with chronic obstructive pulmonary disease (COPD) and an 68 year old female with asthma. Before we review the options, let's look at the question. The key words in a question should be identified. The key words in this question are clients, assign, and same room. Each option stands alone with the question. After reviewing the question, look at each option and identify if it is true or false. Option 1 is true. Ask yourself which groups of clients have something in common. The client post-operative appendectomy and the client with nephrolithiasis will both need to be frequently assessed for pain and interventions aimed at pain management. Also neither client has an infection that could be transmitted to the other client. Option 2 is false. The client with neutropenia has a low number of neutrophils which are a common type of white blood cell important to fighting off infections. The client should assigned to a private room. In addition the other client could be contagious depending on the causative factor of the nausea,vomiting and diarrhea. The client with neutropenia should not be assign with this client since their diagnosis has not been identified.. Option 3 is false. Contact isolation is required for both MRSA and C. difficile but the causative organisms for the diseases are not the same. Option 4 is false. The age difference between teenager and the elderly adult are so vast that the developmental needs of the clients vary too much for them to be placed in a room together. Option 5 is true. Neither client has an infectious disease. The clients with bronchitis and COPD have similar respiratory conditions that are not infectious.

A 68 year old client was admitted two days ago to a long term care facility. The client has chronic kidney disease, coronary artery disease and chronic obstructive pulmonary disease. Oxygen 2 L/min by nasal cannula is being administered. Assistance is needed with activities of daily living. The primary healthcare provider visits today and writes new prescriptions. Who is the best person for the charge nurse to delegate carrying out these prescriptions?

LPN/LVN All the nursing responsibilities associated with the primary healthcare provider's prescriptions are within the scope of practice of the LPN/LVN. The UAP cannot carry out all of the prescriptions. The charge nurse should not delegate to the RN those things that the LPN can do. So the best person to delegate these responsibilities to is the LPN.

An LPN/VN has been floated to the emergency room following a chemical plant explosion. What task would be best for LPN/VN to accept?

1. Identify and assess each incoming client. 2. Triage and assign color-coded tags to each client. 3. Gather and apply dressings to open wounds. 4. Initiate oxygen and IV lines as needed. 3. Correct: An LPN/VN's scope of practice includes tasks such as wound care. Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. If the LPN notes any serious bleeding situations, it would need reported immediately to the RN. 1. Incorrect: Although it will be crucial to identify each incoming client, the LPN/VN's scope of practice does not include assessment. That task would require an RN or primary healthcare provider. 2. Incorrect: In a mass casualty situation, triage allows the nurse or primary healthcare provider to quickly determine which clients are critical versus those stable enough to wait. Because this involves assessment, an LPN/VN would not be assigned this task. 4. Incorrect: Initiating intravenous lines is not within the scope of the LPN/VN. Additionally, the decision to apply oxygen involves assessment of the respiratory system, which also is not within the LPN/VN's scope of practice.

A cardiac step down unit has requested float staff because of multiple impending admissions. The supervisor can only send one LPN to the floor. Which assignments would be appropriate for the LPN to accept from the charge nurse?

1. A client with COPD complaining of shortness of breath on exertion. 2. A post-cardiac catherization needing assistance with bedpan. 3. A client receiving heparin injections for deep vein thrombosis. 4. A client with atrial fibrillation currently on a diltiazem drip. 5. A client receiving a blood transfusion that requires monitoring. 6. A client post pacemaker insertion, awaiting discharge instructions. Whenever a nurse is pulled to an unfamiliar unit or a unit where clients have different diagnoses that what that pulled nurse is used to caring for, that nurse should be assigned stable, predictable clients. Remember the LPN/VN can care for stable clients with acute or chronic illnesses. The key is that the client is stable. So let's look at our options. So which of these six clients are stable? Did you say options 1, 3, and 5? Option 1. Remember the LPN/VN can care for stable clients who are complicated and have a long term illness. This client has SOB on exertion which is a typical finding in the COPD client. Option 3. The LPN/VN can give heparin injections to a client with DVTs. Option 5. Can the LPN/VN monitor a client receiving blood? Yes. The RN starts the blood but the LPN/VN can monitor the blood once started. So why can't the LPN/VN care for clients in options 2, 4, and 6? These are all cardiac clients who are complicated and unstable or need teaching,

A client with altered level of consciousness is admitted to a medical unit, the nurse finds the client with no pulse and initiates CPR. The primary healthcare provider instructs the respiratory therapist to prepare for intubation. The nurse discovers a Do Not Resuscitate (DNR) bracelet on the client's wrist during the initial assessment. Which immediate action should the nurse take to advocate appropriately for this client?

1. Assist the respiratory therapist to prepare the client for immediate intubation. 2. Attempt to contact the client's family. 3. Notify the primary healthcare provider immediately of the client's DNR bracelet. 4. Notify the charge nurse immediately of the client's DNR bracelet. 3. Correct: The nurse should immediately notify the primary healthcare provider upon discovering the client's DNR bracelet. The DNR bracelet is an indicator that the client or their healthcare surrogate decision maker wants the client's wishes be known regarding healthcare treatment and resuscitation. 1. Incorrect: Ignoring the DNR bracelet and assisting the respiratory therapist to prepare for immediate intubation is incorrect because the client has a DNR notification on their person and should not be intubated. 2. Incorrect: Reaching the client's family allows the family to be with the client and to provide additional health history, but this should be done after notifying the primary healthcare provider. 4. Incorrect: Notifying the charge nurse of the client's DNR bracelet is not priority. The primary healthcare provider must be notified first.

Which tasks could the LPN/VN working on a telemetry unit assign to an unlicensed assistive personnel (UAP)?

1. Bathe the client who is on telemetry. 2. Apply cardiac leads and connect a client to a cardiac monitor. 3. Assist with a portable chest x-ray. 4. Feed a client who is dysphagic. 5. Collect a stool specimen. 1., 2., 3., & 5. Correct: Remember the nurse cannot delegate assessment, teaching, evaluation, medications, or an unstable client to the UAP. The UAP could bathe the client who is on telemetry. This is an appropriate assignment. The UAP can apply cardiac leads and connect the client to a cardiac monitor. The UAP can assist with helping the client sit up for a portable chest x-ray as long as the UAP is not pregnant and wears a shield. The UAP can collect specimens, such as a stool specimen. 4. Incorrect: This client is at risk for choking and is not stable; therefore, the nurse should not allow the UAP to feed this client

As a member of the emergency preparedness planning team at the hospital, which actions should the nurse encourage the team to implemento?

1. Developing a response plan for every potential disaster. 2. Providing education to employees on the response plan. 3. Practicing the response plan on a regular basis. 4. Evaluating the hospital's level of preparedness. 5. Assigning all client care duties to the Nursing Supervisor. 2., 3. & 4. Correct: Developing a single response plan, educating individuals to the specifics of the response plan, and practicing the plan and evaluating the facility's level of preparedness are effective means of implementing emergency preparedness. The basic principles of emergency preparedness are the same for all types of disasters. Only the response interventions vary to address the specific needs of the situation. 1. Incorrect: One good response plan, not multiple plans, should be developed. This will ensure adequate understanding of the plan and decrease confusion of roles that could occur with multiple plans. There is no feasible way for the hospital to have a response plan for every potential disaster. 5. Incorrect: All client care duties cannot safely be assigned to one caregiver. The nursing supervisor needs the help of other staff to carry out nursing care for the clients in the hospital.

The nurse is assisting the community health nurse to plan a discussion on how to prevent pesticide ingestion at a local health fair. What should the nurse include in this discussion?

1. Discard the outer leaves of lettuce. 2. Wash fruits and vegetables with dish soap. 3. Buy organic produce. 4. Peel fruits prior to eating. 5. Dry produce thoroughly with disposable paper towels after washing. 6. Use a scrub brush when washing fresh fruits and vegetables. Before we review the options, let's look at the question. The key words in a question should be identified. The key words in this question are community health nurse, prevent pesticide ingestion, health fair, and teaching session. Each option stands alone with the question. After reviewing the question, look at each option and identify if it is true or false. Remember client safety is always a priority. The question is asking about a teaching session to prevent pesticide ingestion. So let's look at the options. Option 1 is true. The outer leaves of green, leafy vegetables such as lettuce, and cabbage should be discarded as pesticide residue likely remains there. Option 2 is false. One of the most common mistakes people make in their attempt to remove all pesticide residue from their produce is that they wash their fruits and vegetables with dish soap. Unless the soap is entirely made of natural and organic materials, it tends to contain harmful compounds that easily penetrate the skin of the fruits. Simply wash with tap water. Option 3 is true. Another great idea to reduce overall exposure to pesticides is to buy organic foods. Organic foods are grown without the use of pesticides or synthetic fertilizers. Option 4 is true. If you can't buy organic, peel fruit and vegetables prior to eating. Option 5 is true. Washing your fruits and veggies is not enough if you want to reduce the pesticide load you expose yourself to, as it is very important to thoroughly dry them with disposable paper towels as well. This will remove all the remaining pesticide residue and make the produce safer to eat. Option 6 is true. A scrub brush is very effective in cleaning the crevices and areas around the stem. The scrub brush should not break the skin of the produce

The nurse cares for a client who takes multiple antibiotics for treatment of an infection. The microbiology laboratory informs the nurse the client's stool is positive for Clostridium difficile. Which actions are most appropriate for the nurse to take?

1. Use standard precautions. 2. Perform hand hygiene by using alcohol hand rub. 3. Implement contact precautions. 4. Perform hand hygiene by washing hands with soap and water. 5. Implement droplet precautions. 1., 3. & 4. Correct: Since Clostridium difficile is a spore (killed by sterilization), the friction performed during washing hands with soap and water rinses organisms off the hands. The nurse should also implement standard and contact precautions to protect the client and the nurse. 2. Incorrect: Clostridium difficile is killed only by sterilization but can be removed with the friction of hand washing. Alcohol based products do not kill Clostridium difficile. 5. Incorrect: Droplet precautions will not prevent the spread of Clostridium difficile