HESI Safety & Infection Control

Which musculoskeletal changes directly place pregnant clients at increased risk for falls? Select all that apply. One, some, or all responses may be correct.

Joint laxity Impaired balance Shifting center of gravity Rationale: Pregnant women are at increased risk of falling directly due to joint laxity, impaired balance, and the shifting center of gravity. Back pain and weight gain do not directly contribute to the increased risk of falling for pregnant women.

Which internal disaster may create a need for evacuation or relocation of clients?

Gas explosion Rationale: A gas explosion is an internal disaster that creates a need for evacuation or relocation. A hurricane or earthquake are natural disasters and are external. The use of explosive devices for a terrorist attack is also an external disaster.

Which are the benefits of providing culturally competent care? Select all that apply. One, some, or all responses may be correct.

Increased client safety Reduced health disparities Increased client satisfaction Rationale: Cultural competence is the ability to understand, appreciate, and work with individuals from cultures other than one's own and involves awareness and acceptance of differences. Cultural competence leads to increased client safety, reduced health disparities, and increased client satisfaction. Cultural competence does not limit the number of visitors that clients receive. Cultural competence does not ensure adequate interpreters; however, there are other means of facilitating communication, such as translation devices, that can be useful.

According to the Healthy People 2020 initiative, which issue will the public health nurse discuss when addressing safety and infection control in adolescents?

Testing all adolescents for human immunodeficiency virus (HIV) before adulthood Rationale: The Healthy People 2020 initiative includes the goal of testing all adolescents for HIV infection before adulthood. Safe sex, alcohol use, and binge drinking are important topics to discuss with adolescents but are not part of the Healthy People 2020 initiative. Pap smears are obtained beginning at age 21, not 16, and are performed annually thereafter.

Which response by the nurse who is earning certification as a member of the Disaster Management Assistance Team (DMAT) indicates accurate understanding regarding the responsibilities of the team?

"I will be expected to work a 3-day shift with the supplies we are given." Rationale: A DMAT is a medical relief team made up of civilian medical, paraprofessional, and support personnel that is deployed to a disaster area with enough medical equipment and supplies to sustain operations for 72 hours (3 days). Being a member of the DMAT does not indicate designation as facility incident commander. The team is made up of several different types of health care providers, not just nurses. Because the DMAT is activated by state and federal government authorities, the Good Samaritan law does not cover the actions of the team.

A child becomes cyanotic during a generalized tonic-clonic seizure. Which is the most appropriate action by the nurse?

Continuing to observe the seizure Rationale: The child's status and the progression of the seizure should be monitored; the child will not breathe until the seizure is over, and cyanosis should subside at that time. Attempting to open a clenched jaw may result in injury to the child. O 2 is useless until the child breathes when the seizure is over. The practitioner may be notified later; provisions for the child's safety and observation are the priorities.

A client with cancer of the tongue has radon seeds implanted. The plan of care states that the client is to receive meticulous oral hygiene. How would the nurse implement the plan?

Using a gentle spray of normal saline Rationale: Gentle sprays are effective in cleaning the mouth and teeth without disturbing the sensitive tissues or radon seeds. Offering a firm-bristled toothbrush can dislodge the radon seeds and be traumatic to the compromised oral mucosa. An antiseptic mouthwash is an astringent that is too harsh for the sensitive oral mucosa. Swabbing the mouth with a moistened gauze square can dislodge the radon seeds and be traumatic to the compromised oral mucosa.

Which report by the client post transrectal prostate biopsy needs to be communicated to the health care provider as a possible sign of infection?

Discharge from the penis Rationale: Discharge from the penis should be communicated to the health care provider for possible infection because discharge is an indication of infection. Soreness, rust-colored semen, and light rectal bleeding are expected after transrectal prostate biopsy.

The nurse is caring for a client taking a selective serotonin reuptake inhibitor (SSRI) for depression. Which statement by the client requires additional teaching?

"I can stop taking this medication when I feel better." Rationale: Clients should never abruptly discontinue an SSRI, because this can cause withdrawal syndrome. The symptoms of withdrawal include dizziness, nausea, sensory disturbances, and dysphoria. Clients will be instructed to take the medication at the same time every day, to increase exercise if the medication contributes to weight gain, and to report any increase in anxiety or agitation to the health care provider.

When donning sterile gloves, how would the nurse glove the second hand?

Insert gloved fingers under cuff of second glove and lift glove; then slide ungloved hand into glove. Rationale: Sterile gloves can only be handled by sterile equipment, or they are contaminated. The sterile glove that has been donned may touch under the cuff on the sterile surface as the nondominant hand is inserted. The sterile glove may not touch the inside of the glove. Donning a sterile glove and placing below the waist means contamination, because under the waist or in back is contaminated. Grasping by the cuff (folded edge) means the inside of the glove has been touched.

Which would the nurse conclude about isolation for the child admitted to the pediatric unit with a diagnosis of meningococcal meningitis?

It will be necessary for 24 to 72 hours after the initiation of antibiotic therapy. Rationale: The meningococcal organism is rendered inactive after 24 to 72 hours of antibiotic therapy; isolation is not required after this time. Meningitis is not evident during the incubation period. The presence of a fever is not the influencing factor indicating the need for isolation. After the diagnosis of meningitis is confirmed, isolation is required for 24 to 72 hours after the institution of antibiotic therapy.

Which assessment technique will the nurse avoid in a client with a suspected hematological disease?

Palpating the abdominal left upper quadrant Rationale: Splenomegaly and risk for rupture of the spleen may occur with hematological diseases. Palpation of the left upper quadrant of the abdomen would be avoided in the client with hematological disease because of the risk of rupturing an enlarged spleen. Heart sounds are auscultated for regularity and abnormal sounds. Checking for costovertebral angle tenderness would not increase risk for splenic rupture. Inguinal lymph node palpation would not increase pressure on the spleen.

Which action is the priority after a home care nurse arrives to visit a client who states he or she has attempted suicide by ingesting paint thinner and then collapses?

Contact 911. Rationale: The priority response in the poisoned client that collapses or stops breathing is to contact 911 for emergency help and begin cardiopulmonary resuscitation (CPR). Do not induce vomiting because this can cause more harm to the gastrointestinal tract. In the alert client, call the poison control center before performing any interventions. Placing the client in a side-lying position to prevent aspiration may be indicated but not until 911 is contacted and CPR is not needed.

The nurse prepares a chart listing the methods of treatment of different types of poisoning in preschool children. Which preschooler's entry needs to be corrected?

Preschooler A Rationale: Activated charcoal is contraindicated for the treatment of corrosive ingestion because it may infiltrate burned tissue. While treating iron poisoning, whole bowel irrigation may be used if radiopaque tablets are visible on an abdominal x-ray exam. To treat plant poisoning, the skin or eyes exposed to the poisonous plant should be washed. Metabolic acidosis caused by aspirin poisoning can be treated with sodium bicarbonate transfusions.

Which unit in the hospital would be the priority for implementation and evaluation of a workplace violence protection plan as one component of a hospital disaster plan?

Emergency department Rationale: The Emergency Nursing Association (ENA) supports comprehensive workplace violence prevention plans to be included as a component of the organizational disaster plan. The ENA recommends that the comprehensive workplace violence prevention plan be implemented and evaluated in every emergency department. Medical units, surgical units, and maternity departments may also require such plans; however, these units have system barriers that decrease the risk for violence when compared with emergency departments.

Which would be included in the plan of care for an obstetrical client who has been taking carbamazepine throughout the first trimester of pregnancy?

Evaluation for a neural tube defect Rationale: Carbamazepine is associated with neural tube defects. Fetal hydramnios, cardiac malformation, and Down syndrome are not related to the use of carbamazepine.

For which care activities would the nurse apply a mask, eye protection (goggles), or face shield? Select all that apply. One, some, or all responses may be correct.

Suctioning a nasotracheal tube Irrigating an abdominal wound Rationale: The nurse should apply a mask, eye protection, or a face shield when conducting procedures and client-care activities that are likely to generate splashes or sprays of blood, body fluids, or secretions such as suctioning a nasotracheal tube or irrigating an abdominal wound. The nurse is not likely to be splashed with blood, body fluids, or secretions when changing an infusion bag, preparing an enteral feeding, or when inserting an intravenous catheter.

A client reports being physically abused by his or her partner. Which interventions would the nurse include in the plan of care? Select all that apply. One, some, or all responses may be correct.

Assess level of danger Notify adult protective services Guidelines for interviewing a victim of domestic violence include assessing the current level of danger and notifying adult protective services. The nurse would explain to the client the required process for notifying the agency of the abuse. The nurse would not press for information the client is not comfortable providing. The nurse would use language the client understands and avoid medical terminology. The nurse would also interview the client in a private area without others around.

Which information would be included in the teaching plan for the mother of a newborn with exstrophy of the bladder?

Protecting the skin surrounding the exposed bladder Rationale: Constant drainage of urine on the skin promotes excoriation and infection, so the skin must be protected. Sterility is impossible to maintain because of the leakage of urine. Output will be difficult to measure because of the constant leakage of urine. A pressure dressing is contraindicated, because it will traumatize the exposed bladder.

Which characteristics describe a second order change in a disaster? Select all that apply. One, some, or all responses may be correct.

Revolutionary and episodic change Change requiring radical adjustments in a person or in the structure of the system Rationale: A second order change is an unanticipated or unexpected change that may occur as a result of disaster in a health care system. Second order change is revolutionary and episodic and requires radical adjustments in a person or in the structure of the system. First order change involves harmony with people or systems. This type of change is evolutionary with continuous improvement and includes small ongoing steps to make things better to sustain the change.

An adolescent girl with a seizure disorder refuses to wear a medical alert bracelet. Which would the nurse tell the girl that may help her wear the bracelet consistently?

Select a bracelet similar to bracelets worn by her peers. Rationale: Because adolescents have a developmental need to conform to their peers, the teenager should be able to select a bracelet of a design similar to that of those worn by her peers. Hiding the bracelet under long-sleeved clothes might be acceptable in cool weather, but not when it is warm and friends are wearing T-shirts. The bracelet should be worn at all times when the girl is not with responsible family members. Asking friends to wear a similar bracelet may be difficult, especially if the girl does not wish to tell her friends why she needs the bracelet.

Which factors would the nurse include when discussing adolescent signs of gang membership with parents?

Substance abuse Rationale: An adolescent's membership in a gang can be associated with substance abuse. Isolation, depression, and suicidal ideation are not signs typically associated with gang membership.

After the nurse has instructed a client with active tuberculosis (TB) on self-care at home, which client statement indicates understanding of the teaching?

"I will plan to stop drinking alcohol during treatment." Rationale: The medications used for treatment of TB can be toxic to the liver, and other substances that are hepatotoxic (such as alcohol) should be avoided during TB treatment to decrease the risk for liver damage. The medications must be taken for 6 months or longer to complete therapy; treatment should not be discontinued when symptoms subside. A client's health care provider will review current medications and let the client know if any should be stopped while being treated for TB, although most medications are safe to take with the medications used to treat TB. Most clients who are taking medications are not contagious after several weeks of treatment. A client who has started TB treatment and has had negative sputum cultures is not contagious and may return to usual activities such as having visitors, although the client will need to continue treatment for at least 6 months.

Which statement from a pregnant client with premature rupture of membranes (PROM) demonstrates an understanding of the infection risk? Select all that apply. One, some, or all responses may be correct.

"I will report a fever to my doctor." "I will wipe from front to back when using the bathroom." "If I have contractions, medications will be administered." "If I develop chorioamnionitis, my doctor will induce labor." "I will let my doctor know if I experience foul-smelling vaginal discharge." Rationale: The nurse would provide thorough education on signs of infection, infection prevention, and possible outcomes of infection for pregnant clients with PROM. The client would be instructed on how to keep the genital area clean and advised that nothing is to be introduced into the vagina. The client would be made aware of the importance of being vigilant for signs of infection, such as fever and foul-smelling vaginal discharge, and that these signs would be reported immediately. Clients would be made aware that labor will need to be induced if chorioamnionitis develops. If preterm labor occurs, tocolytic medications can be administered to "buy time" enough for transporting the client to a hospital capable of providing preterm infant care. The additional time also allows antenatal corticosteroids or antibiotics to reach effective levels.

The nurse is providing instruction to a parent of a child with influenza. Which statement by the parent indicates the need for further instruction?

"I'll manage the fever with baby aspirin." Rationale: The use of aspirin to treat the fever associated with influenza is contraindicated; it is associated with Reye syndrome, which involves a toxic encephalopathy and hepatic dysfunction. Inactivated influenza viral vaccines are effective in the prevention of influenza. Fever may lead to dehydration; fluids help maintain hydration. The influenza virus can be spread by direct contact or through contact with surfaces contaminated with the virus; staying home prevents the spread of the disease to other students. "I'll manage the fever with baby aspirin" indicates the need for further instruction. Baby aspirin should not be given to children who have a fever or viral illness due to the risk of developing Reye's syndrome, a rare but serious condition that can cause liver and brain damage. Acetaminophen or ibuprofen are the recommended medications for managing fever in children with influenza. The other three statements are all correct. Getting a flu shot, providing fluids, and staying home from school are all important measures in preventing the spread of influenza and helping the child recover from the illness.

Which statement would the nurse include when providing suicide prevention teaching? Select all that apply. One, some, or all responses may be correct.

"Suicidal behavior is the leading cause of psychiatric hospitalization for young children." Rationale: There are many myths about suicide. When teaching on the subject, the nurse would provide the facts as well as dispel common myths and misunderstandings about suicide. It is a fact that suicide is the third leading cause of death in persons 15 to 24 years of age, and the rate for children ages 10 to 14 years of age has doubled since 1980. The nurse would include the statement that suicidal behavior is the leading cause of psychiatric hospitalization for young children. Mental illness, particularly depression, is a high-risk factor for suicide, but not all suicidal persons are depressed. Poverty is a risk factor, but suicide occurs in all socioeconomic classes. The nurse demonstrates interest and concern by discussing suicide with clients who are at risk; this is usually beneficial to these individuals. People who are serious about suicide often provide clues such as tidying up their affairs and giving away possessions. Manipulation is not typically a factor in suicide.

A client expresses concern regarding the lack of annual flu vaccines because of a supply and demand problem. Which response by the nurse is best?

"There are other things you and your family can do to prevent the flu, such as hand washing." Rationale: The statement "There are other things you can do to prevent the flu, such as hand washing" is a teaching opportunity of which the nurse can take advantage and show the client the things that can be done to avoid infection. The response "It's unfortunate, but there was such a limited supply available" is empathic, but it does not address the client's concern of vulnerability. The response "There are many others who also were unable to get a flu vaccine" belittles the client for being concerned. The response "It doesn't matter because the vaccine is for just one particular strain" may be true, but it belittles the client's concern.

A new mother asks the nurse administering erythromycin ophthalmic ointment to her newborn why her baby must be subjected to this procedure. Which is the best response by the nurse?

"This antibiotic helps keep babies from contracting eye infections." Rationale: Erythromycin ophthalmic ointment is used to treat infections cause by Neisseria gonorrhoeae and Chlamydia species, which may be transmitted during birth. It is administered prophylactically. Although it will prevent the newborn from becoming blind if the infant is born with these infections, there is not enough information in the answer to help the mother understand how the ointment prevents blindness. The antibiotic ointment is not administered to protect the newborn from bright lights. Newborns are in fact required by law to receive erythromycin ophthalmic ointment, but simply stating this does not explain why it is administered.

Which client in an emergency department requires immediate treatment based on condition after a lightning strike?

A Rationale: Lightning strikes can cause cardiopulmonary arrest due to the effect of a massive electrical current discharge on the cardiopulmonary system. Client A should be treated first. Mottled skin and decreased peripheral pulses arise due to arterial vasospasm and resolve spontaneously in several hours. Client B can be treated after client A is treated. A lightning strike can result in temporary paralysis that affects the lower limbs to a greater extent than the upper limbs, but client C does not require immediate treatment. A client with post-traumatic stress disorder can be treated after clients A, B, and C.

The nurse is preparing to assess a client with peptic ulcer disease (PUD). Which assessment finding indicates a need for immediate health care provider notification?

Black stools Rationale: Black stools indicate the presence of blood in the stool and needs to be immediately reported to the health care provider. Nausea, dyspepsia, and dull abdominal pain are minor clinical manifestations and can be managed with medications. Black stools indicate the presence of gastrointestinal bleeding and would require immediate health care provider notification. Peptic ulcer disease (PUD) is a condition that can cause bleeding in the gastrointestinal tract, which may manifest as black, tarry stools. Nausea, dyspepsia (indigestion), and dull abdominal pain are common symptoms of PUD, but they do not necessarily indicate an urgent need for health care provider notification unless they are severe or accompanied by other concerning symptoms. However, the presence of black stools should prompt immediate assessment and treatment to address the source of the bleeding.

Which information about decreasing the risk for complications would the nurse provide to a pregnant adolescent who remains sexually active with other partners? Select all that apply. One, some, or all responses may be correct.

Calcium consumption Exercise Folic acid Condom use Prenatal care Rationale: The nurse would provide information on nutrition, which would include consuming enough calcium for bone strength. Exercise is important to maintain health, control blood pressure, and prevent too much weight gain. Folic acid supplementation prevents neural tube defects. Condom use is essential because pregnancy does not prevent the client from acquiring sexually transmitted infections. Prenatal care is essential to monitor fetal growth and detect complications early.

A client has a large, open abdominal wound. The health care provider's prescription states to cleanse the wound with normal saline, pack it with damp gauze, cover with abdominal pads, and secure with Montgomery straps twice a day. Which step would the nurse take to maintain sterility when changing the dressing?

Cleanse the wound with wet, sterile gauze from the center of the wound outward. Rationale: Wounds should be cleansed from the center outward or from the top to the bottom; this ensures that cleansing is done from the least to the most contaminated area. A new sterile gauze square should be used for each swipe of the wound. More than two gauze squares will be needed to cleanse a large abdominal wound. Using the same gauze square again will contaminate the wound. Montgomery straps are changed only when they become soiled or begin to loosen from the client's skin. Montgomery straps are applied to each side of a wound. The central sections are folded back when the dressing is changed. When folded back in place over the new dressing and secured with a tie, they keep the dressing in place without having to replace the tape each time the dressing is changed. Forceps should always be held with the tips lower than the wrist. If they are held with the wrist lower than the tips of the forceps, cleansing solution can flow down the instrument and the hand and arm of the nurse, contaminating the fluid. When the wrist is then raised above the forceps, the contaminated fluid will flow back down the forceps into the wound.

A client with a methicillin-resistant Staphylococcus aureus (MRSA) infected wound is scheduled for a computed tomography (CT) scan. To ensure client and visitor safety during transport, the nurse would implement which precaution?

Cover the infected site with a dressing. Rationale: Covering the infected site with a dressing will contain secretions and set up a barrier, thus decreasing the risk for transmission to others. Contact precautions must be used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment. Draping the client with a sheet marked biohazardous does not protect the client's privacy. A wound infected with MRSA can be transmitted to others via contact, not through the airborne route; thus a mask is unnecessary.

Which events indicate a need to suggest testing of a client for the human immunodeficiency virus (HIV)? Select all that apply. One, some, or all responses may be correct.

Diagnosed with tuberculosis in 1985 Received blood transfusions in 1980 during total hip replacement surgery Engaged in sexual relations with someone of the same sex for several years Rationale: Reasons for a client to be tested for HIV include diagnosis with a communicable disease such as tuberculosis, receiving blood transfusions before blood was routinely tested for HIV contamination, and engaging in sexual relations with a member of the same sex. Travel to Italy and Greece and spending several nights in jail because of a DUI would not require testing for HIV.

A mother diagnosed with acquired immunodeficiency syndrome (AIDS) states she has been caring for her baby even though she has not been feeling well. Which important information would the nurse determine regarding the care provided by the mother?

If the mother is breast-feeding her baby Rationale: Epidemiological evidence has identified breast milk as a source of human immunodeficiency virus (HIV) transmission. Kissing is not believed to transmit HIV. When the baby last received antibiotics is unrelated to transmission of HIV. HIV transmission does not occur from contact associated with caring for a newborn. All of the options presented are important factors to consider, but the most crucial information to determine first is whether the mother is breastfeeding her baby or not. If the mother is breastfeeding, the baby may have been exposed to the human immunodeficiency virus (HIV), which causes AIDS, through breast milk. It is recommended that mothers with HIV do not breastfeed their infants to prevent transmission of the virus. If the mother has been kissing the baby or has been caring for the baby while feeling unwell, there is a risk that the baby may have been exposed to other infections, but the risk of HIV transmission through casual contact is very low. Knowing when the baby last received antibiotics and how long the mother has been caring for the baby would also be important information to have, as this can help the nurse determine if the baby is at risk for developing an infection.

Which nursing interventions are the most appropriate to prevent further injury in the client who was injured in a hurricane and now is confused? Select all that apply. One, some, or all responses may be correct.

Keeping the side rails up on the stretcher Maintaining adequate lightening in the room Asking a family member to remain with the client Reminding the client to use the call light for assistance Rationale: Keeping the side rails up on the stretcher will help reduce falls and prevent injury in the client. Maintaining adequate lighting in the room will help prevent injury, because there may be a chance of a fall in a dark room. Asking a family member or significant other to remain with the client will help reduce confusion. Reminding the client to use the call light for assistance may prevent injury because the client is confused and may need staff assistance. Providing the client with an ID bracelet is useful for client`s identification, but may not prevent injuries. Obtaining a thorough client and family history may not help in preventing injuries.

Which immediate nursing intervention is most appropriate for the client with an eye injury from exposure to a chemical blast?

Performing ocular irrigation Rationale: In case of chemical burns, ocular irrigation with saline water should be performed immediately. Assessing the visual acuity is not the most appropriate intervention for chemical burns. Determining the mechanism of injury is performed as an initial intervention in case of eye accidents but not for chemical burns. The nurse would ask the client not to blow the nose in cases of chemical burns.

When preparing to safely administer medications to newborns, it is important for the nurse to recognize which factors as contributors to reduced renal medication excretion? Select all that apply. One, some, or all responses may be correct.

Renal blood flow Glomerular filtration Active tubular secretion Rationale: In newborns, renal blood flow, glomerular filtration, and active tubular excretion contribute to reduction of renal medication excretion. Bladder capacity is not associated with the reduction of renal excretion in newborns. The nephron is a structural and functional unit of the kidneys.

The nurse is preparing to administer methylphenidate to an older adult with apathy and depression. Which would the nurse include in the assessment to monitor for complications? Select all that apply. One, some, or all responses may be correct.

Vision Weight Heart rate Rationale: When methylphenidate is administered to older adults, the nurse will monitor the client's vision for signs of glaucoma, as well as their weight, heart rate, and blood pressure. Skin turgor and bowel sounds are not affected by methylphenidate.

The nurse teaches a client about strategies to reduce burn injuries. Which statement made by the client indicates the need for further teaching?

"I should never leave burning candles near open curtains unattended." Rationale: The client should never leave candles unattended near open curtains. The client should never smoke in bed, use gasoline to start a fire, or leave hot oil unattended while cooking.

The new nurse is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. Which answer by the nurse is correct?

"Wash your hands before and after any client care." Rationale: The best means to prevent the spread of infection is to break the chain of infection. This is most easily accomplished by the simple act of hand washing before and after all client contact. "Let me get my preceptor" and "Clean all instruments and work surfaces with an approved disinfectant" may be correct, but they are not the best responses for this situation. It is not necessary that all items contaminated with blood or body fluids be disposed.

The nurse is reviewing the medical record of a client taking lithium for the management of bipolar disorder. Which finding indicates safe therapeutic levels of the medication?

0.7 mEq/L Rationale: Health care providers prefer lithium levels to be between 0.6 and 0.8 mEq/L. Therefore 0.7 indicates therapeutic safe medication levels. A lithium level of 0.3 mEq/L is subtherapeutic. Lithium levels between 0.8 to 1.0 mEq/L can have more adverse effects. A lithium level of 1.7 mEq/L is significantly toxic and unsafe.

Which action would the nurse take during a falls risk assessment after learning that the client experienced a recent fall?

Assessing the circumstances of the fall, including feelings and setting Rationale: The circumstances of the fall, including feelings and setting, should be explored and documented to understand risk of falls for this client. Fall history alone does not warrant use of restraint. The nurse consults with the health care provider on polypharmacy but does not discontinue medications independently. The family is not required to remain at the bedside but is encouraged to understand fall risk.

When a client is taking varenicline for smoking cessation, which symptom reported by the client is most important for the nurse to communicate to the health care provider?

Changes in behavior or thought processes Rationale: Varenicline can bring on or worsen serious mental health issues, including depression, paranoia, hallucinations, delusions, and suicidal ideation. The nurse will immediately report any changes in a client's behavior or thought processes to the health care provider and anticipate that the medication will be discontinued. Headache is a potential adverse effect but does not require discontinuation of the medication. Upper respiratory symptoms may occur but are not an indication that the medication should be immediately discontinued. When treatment begins, it is expected that the client will have the desire to smoke. As treatment continues, the desire should lessen if the medication is effective.

Based on their conditions, which client would be triaged first according to the 3-tiered triage system?

Client A Rationale: Client A reporting chest pain is considered to have a life-threatening condition and is triaged as emergent. Clients B and C having displaced or multiple fractures and renal colic need quick treatment but are not considered to have immediately life-threatening conditions, particularly when compared with client A's condition. They are triaged in the urgent tier level. Client D with strains and sprains is triaged as nonurgent because this client has strains and sprains and can wait for treatment.

Which medication is most beneficial to the client with sickle cell anemia on a blood transfusion regimen who has cardiac dysrhythmias due to iron overdose toxicity?

Deferoxamine Rationale: A client with sickle cell anemia requires frequent blood transfusions and is at an increased risk for iron toxicity. Deferoxamine is an intravenous medication that chelates with the iron and reduces iron overload or hemochromatosis in the client in less time. It is the most beneficial medication in this situation. Deferasirox and deferiprone are oral chelating agents and therefore show delayed action compared with deferoxamine. Iron supplements such as ferrous gluconate should not be administered to the client, because they further increase the risk of iron overload.

Which athletic safety equipment would the nurse recommend for a school-aged child? Select all that apply. One, some, or all responses may be correct.

Helmet Padding Eye shields Mouth shields Rationale: General safety equipment recommended for a school-aged child playing active sports includes a safety helmet, padding, eye shields, and mouth shields. Gloves are not necessary unless participating in a specific activity that requires them.

Which nursing intervention is most important for preventing injury to a client preparing to undergo electroconvulsive therapy (ECT) treatment?

Implement seizure precautions. Rationale: ECT therapy uses an electrical current to stimulate seizure activity. The nurse would implement seizure precautions to protect clients from injury. Baseline vital signs would be obtained to assess cardiac and respiratory function, but this action is not the priority for client safety. The nurse would need to evaluate a client's ability to swallow after, not before, the ECT. Benzodiazepines would be discontinued before the treatment, because these medications prevent the onset of seizures.

The nurse is preparing to administer an acid-labile prescription to an 18-month-old. Which rate of medication absorption would the nurse need to be mindful of to administer the medication safely to this client?

Increased Rationale: Gastric activity does not reach adult values until a child is 2 years of age. Due to low gastric acidity, absorption of acid-labile prescriptions will be increased, rather than decreased, in this age group. Any prescription can be unpredictable in a child, but unpredictability of absorption is not specifically associated with an acid-labile prescription. It would be expected that the child will be able to absorb the prescription.

Which would the nurse instruct the unlicensed assistive personnel (UAP) to perform to prevent hip dislocation in a client recovering from a total hip arthroplasty via posterior approach?

Insert abduction pillow between legs. Rationale: The nurse will instruct the UAP to insert an abduction pillow between the legs of a client recovering from total hip arthroplasty via posterior approach to prevent dislocation of the hip. Raising the heels prevents skin breakdown. Changing positions slowly prevents injury from orthostatic hypotension. Using a gait belt during ambulation decreases the risk for falls. he nurse would instruct the unlicensed assistive personnel (UAP) to insert an abduction pillow between the legs of a client recovering from a total hip arthroplasty via posterior approach to prevent hip dislocation. This helps to maintain proper alignment of the hip joint and prevent excessive internal rotation or adduction of the hip. Raising heels off the bed and changing positions slowly can help prevent pressure ulcers and orthostatic hypotension, but they are not specific measures to prevent hip dislocation in this scenario. The use of a gait belt during ambulation can help prevent falls, but it does not specifically prevent hip dislocation in a client recovering from a total hip arthroplasty.

Which risk factor increases a client's risk for infection in the community? Select all that apply. One, some, or all responses may be correct.

Lifestyle Occupation Frequent traveling Rationale: Adults are at risk for infection in the community via lifestyle choices such as high-risk behaviors that can lead to human immunodeficiency virus (HIV) and sexually transmitted infections. Occupational hazards include those who work in the mining or health care industries. Frequent travelers can be exposed to infections from other parts of the country or world. Chronic diseases such as pneumonia, skin breakdown, and diagnostic procedures happen in the health care setting.

Which information would the nurse document in the medical record regarding a client's reported allergies? Select all that apply. One, some, or all responses may be correct.

Medication names Type of allergic reaction Epinephrine (EpiPen) use for allergic reaction Rationale: When documenting client allergies, the nurse will include the names of the medications, type of allergic reactions experienced, and any use of an EpiPen to manage symptoms of allergic reactions. Documenting this information in a client's medical record provides communication to other members of the health care team to prevent administration of these medications. It is not necessary for the nurse to record the date the reaction occurred or the client's family history of allergies.

Which discharge education would the nurse provide the parents of a 3-year-old child with thalassemia (Cooley anemia)?

Minimize the risk of infection. Rationale: Children with a chronic illness should not be exposed to the additional stress of an infection. Subsequent to frequent transfusions, the child may have iron overload; an iron-rich diet is contraindicated. Because the child is chronically anemic, the child's fluid intake should be regulated. The child should be encouraged to lead an active life during periods of well-being. The discharge education that the nurse would provide to the parents of a 3-year-old child with thalassemia (Cooley anemia) would be to minimize the risk of infection. Thalassemia is a genetic blood disorder that affects the production of hemoglobin, which is necessary for oxygen transport in the body. As a result, children with thalassemia have a weakened immune system, making them more susceptible to infections. Therefore, it is crucial to minimize the risk of infection by providing the child with good hygiene practices, such as frequent hand washing and avoiding exposure to sick individuals. It is also essential to keep up with the child's vaccinations to protect them from preventable infections. Iron-rich meals are not necessary for children with thalassemia because they already have too much iron in their bodies due to frequent blood transfusions. Encouraging increased fluid intake is also not necessary unless the child is experiencing dehydration. Restricting activity and allowing only quiet play is not necessary for most children with thalassemia. However, it may be necessary if the child is experiencing symptoms such as fatigue or shortness of breath. In general, children with thalassemia should be encouraged to participate in physical activities as long as they are not experiencing symptoms and have been cleared by their healthcare provider.

Which type of needs would be placed as a high priority in the prioritization of client care?

Needs that affect safety Rationale: Needs related to survival and safety are the highest priority because these are an immediate threat to client health. Developmental needs and long-term care needs are low priority when prioritizing care because they are not an immediate threat to health. Potential needs in care are intermediate priority because they are best addressed before complications follow

Which action by the nurse during a fire drill indicates the need for further education on client safety during a fire?

Opens doors for ventilation Rationale: Doors and windows should be closed to contain the fire to the area where it began. Using an ABC fire extinguisher would be appropriate if the fire is small enough. The nurse will remove clients, as well as any oxygen tanks, from the area to prevent injury.

A child with type 1 diabetes has difficulty measuring the required insulin dose. The child frequently draws up 42 units of insulin instead of the prescribed 24 units. Which is the most appropriate intervention to ensure dosage safety?

Providing the child with a preset syringe that was developed for the visually impaired Rationale: The child's problem is caused by perceptual difficulties; the preset syringe removes the need to differentiate between 24 and 42 units. Having the child write the numbers down or use a tuberculin syringe does not solve the problem stemming from the transposition of numbers. The problem is not caused by the inability to see the numbers but by the child's perception of them.

Which nursing intervention is the priority for a client on intravenous medication who is experiencing an anaphylactic reaction?

Stop intravenous medication and administer epinephrine (adrenaline). Rationale: Intravenous medications can cause an anaphylactic reaction. During anaphylactic reactions, the nurse would immediately stop the intravenous medication and administer epinephrine (adrenaline). The nurse can elevate the client's lower extremities, but only after administering epinephrine (adrenaline). The nurse can start a normal saline infusion and report to the primary health care provider, but only after stopping the intravenous medication and administering epinephrine (adrenaline).

The nurse manager is discussing ways to maintain staff safety in a client mental health unit. Which action by the nurse indicates a need for further education?

The nurse wears stethoscope around the neck. Rationale: The nurse would never wear a stethoscope or anything around the neck. The client may grab this and use it to harm the nurse. This nurse's action requires further education. The nurse would move furniture and remove obstacles to prevent injury if client behavior escalates requiring physical intervention. The nurse would remove items from the area that a client can use to harm others. The nurse would refrain from blocking the doorway when talking with clients. This could be considered hostile by the client.

Which are functions of the Hospital Incident Command System (HICS) in disaster management? Select all that apply. One, some, or all responses may be correct.

To standardize disaster operations To establish an emergency operations center (EOC) Rationale: The HICS is the facility-level organizational model for disaster management. It functions to standardize disaster operations. HICS personnel establish an EOC or command center. Disaster Mortuary Operational Response Teams (DMORTs) manage mass facilities. A Disaster Medical Assistance Team (DMAT) is a medical relief team that provides first aid stations. A National Veterinary Response Team (NVRT) is a health care service that establishes emergency animal care.

Which information would the nurse provide in a presentation to a group of women about ways to decrease their risk for becoming victims of crime? Select all that apply. One, some, or all responses may be correct.

Use night-lights. Install exterior lighting. Attach whistle to key ring. Rationale: The nurse would inform the group to use night-lights and install exterior lighting in their houses. This increases security around the home. Attaching a whistle to a key ring can allow the person to alert others for help. The nurse would not advocate carrying weapons because this can lead to more injuries. The nurse would instruct the group to park close to the building under a bright light.

The school nurse presented a program for teachers about infection-control and hand-washing techniques. Which evaluation method is the most effective way for the nurse to evaluate the teachers' knowledge of hand-washing techniques?

Watch the teachers demonstrate infection-control techniques. Rationale: The best way to evaluate learning is by feedback demonstration of precautions related to infection control, such as hand-washing techniques. This method is observable and must meet objective criteria. Although observing a lecture, giving a written examination, or sharing what has been learned in a seminar are all evaluation techniques that may be used, none of these methods are as objective and definitive as observing an actual psychomotor demonstration of techniques.

Which statement indicates misunderstanding of the precautions required for clients infected by the Ebola virus?

"I will not touch the prepared food for the infected client." Rationale: The Ebola virus is not spread via air, water, or food. Avoiding the touching of prepared food for the infected client may not help in preventing Ebola. The nurse should correct this misconception. Clients with Ebola should be isolated in a single room to prevent the spread of infection. While caring for a client with Ebola, the nurse should use standard, contact, and droplet precautions to prevent Ebola infection spread. The nurse should avoid direct contact with body fluids of the infected client to prevent the spread of Ebola infection.

Which would the nurse recommend to overwhelmed new parents to prevent shaken baby syndrome?

"Plan periods of rest so you can have a break." When parents are overwhelmed and unable to comfort a crying baby, they may become frustrated to the point of shaking the baby. This action can cause injury, and even death, to the newborn. The nurse will advise new parents to plan respite periods away so they each can have a break, which will help reduce frustration, exhaustion, and other contributing factors to shaken baby syndrome. The nurse would not instruct the parents to ignore crying, because crying is how a newborn expresses need. Parents may eventually place an infant in daycare, but this would not be recommended specifically to reduce the risk of shaken baby syndrome. An appointment with the child's pediatrician may or may not be necessary and is not an immediate intervention to prevent shaken baby syndrome; new parents need to be instructed on how to cope and obtain respite.

Which long-term care facility staff member statements indicate correct understanding of a disaster response plan for staff and residents? Select all that apply. One, some, or all responses may be correct.

"We have to implement annual drills." "The plan must include an evacuation plan." Rationale: Hospitals are not the only health care agencies that are required to practice disaster drills. Long-term care (LTC) facilities are also mandated to have annual drills to prepare for mass casualty events. Part of the response plan must include a method for evacuation of residents from the facility in a timely and safe manner. Nursing homes are also required to have a disaster response plan. LTC facilities are not held to the same standards as hospital facilities. Insurance payment for medical care is not contingent on the implementation of a disaster response plan.

Which is an example of a sentinel event?

A splenectomy is done on the wrong client. Rationale: A sentinel event is an unexpected occurrence involving death, serious physical injury, or psychological injury. An example of a sentinel event is a splenectomy performed on the wrong client. This could result in long-term effects in the client who did not require a splenectomy, as well as the client who needed the procedure but did not receive it as planned. The nurse has the authority to take vital signs more frequently if deemed necessary, as long as it is not more frequent than hospital policy. The confused client who falls out of bed because the nurse did not put up the ordered siderails is an example of negligence. The client receiving the wrong antibiotic is an example of a medication error.

A client who had a cerebrovascular accident reports feeling lightheaded and dizzy when moving from a lying to a standing position. Which information would the nurse include when explaining the cause of these symptoms?

Blood pooling in the lower extremities Rationale: Dilation of blood vessels causes dependent pooling when the client moves to an upright position, resulting in orthostatic (postural) hypotension. The client can limit feelings of lightheadedness and dizziness by moving gradually when changing positions. Inflammation of peripheral nerves is not the cause of the clinical manifestations. Inflamed peripheral nerves can cause neuropathies. Loss of blood and blood volume causes hypovolemia, leading to shock. Demyelination of peripheral nerves leads to multiple sclerosis.

Which factor places an infant at risk for sudden infant death syndrome (SIDS)? Select all that apply. One, some, or all responses may be correct.

Cigarette smoking Prone sleep position Lower socioeconomic status Rationale: Cigarette smoking, a prone sleep position, and lower socioeconomic status place an infant at risk for SIDS. Breast-fed infants have a lower incidence of SIDS. Low maternal age is a risk factor for SIDS.

Which nursing action is the priority to include in a disaster plan for the radioactive dust and smoke that can cause illness from a radiological dispersal device?

Covering the nose Rationale: Radiological dispersal devices (RDDs), also known as "dirty bombs," consist of a mix of explosives and radioactive material (e.g., pellets). The priority nursing action to protect against the radioactive dust and smoke that can cause illness from an RDD is covering the nose and the mouth to decrease the risk for inhalation. Protecting the eyes is the priority if present during the explosion, but not necessarily when exposed to the subsequent dust and smoke. Decontaminating the skin is important but not the priority. Administering prophylactic antibiotics will not be effective to prevent illness related to an RDD.

Which agent would the nurse deduce was used in a terrorist attack in which all victims at the disaster site have breath with an almond odor?

Cyanide Rationale: Cyanide poisoning can give the breath an almond odor. Almond odor breath is not associated with sarin gas or phosgene; these agents cause paralysis of respiratory muscles and respiratory depression, respectively. Likewise, mustard gas does not give an almond odor to the breath; it results in skin blisters and burns.

Which characteristics of a bully would the nurse include in parental education? Select all that apply. One, some, or all responses may be correct.

Defiant Aggressive Manipulative Rationale: Bullies are generally defiant toward adults, manipulative, and have aggressive attitudes. Children who are targeted for bullying often have internalizing characteristics such as depression and low self-esteem.

When the emergency department nurse expects death in a client critically injured in a bomb blast, which would be the appropriate triage categorization for the client?

Expectant Rationale: Clients who are expected to die or are dead are categorized under class IV triage level or as expectant. Urgent or class II clients are those who require immediate treatment, but can wait for a short period. Emergent or class I clients are those who have an immediate threat to life and require immediate treatment. Nonurgent or class III clients are those who have minor injuries and do not require immediate treatment.

During the hourly assessment of an adolescent's intravenous (IV) line the nurse discovers that the IV did not deliver the prescribed amount during the past hour. Which would the nurse complete first?

Inspect the infusion setup. Rationale: Assessment is the first step in the nursing process. Before the problem is diagnosed and nursing care is planned and implemented, data must be collected to determine the cause of the problem. Increasing the flow rate is unsafe without a primary health care provider's prescription. Assessment may indicate that an independent nursing intervention is required, or it may provide significant information that should be communicated to the primary health care provider. Oral intake is not related to IV intake. Also, the primary health care provider may have prescribed nothing-by-mouth status.

Which assessment is priority after checking airway for a client with a cervical spinal cord injury?

Level of consciousness Rationale: Only after the airway is secured will a client's level of consciousness be assessed as part of the Glasgow Coma Scale. Then vital signs and oxygen are assessed, sensory perception is assessed for impairment, and diaphoresis is assessed if looking for autonomic dysreflexia.

Which aspect of safe medication administration in the pediatric population does the nurse need to consider? Select all that apply. One, some, or all responses may be correct.

Medications can cause unanticipated side effects. Dosing ranges are an important component in the process. Many medications have not been tested in children. Some of the medications may be ineffective in children. Rationale: Fully two-thirds of medications used in pediatrics have never been tested on children. As a result, complete understanding of the pharmacokinetics and both therapeutic and adverse effects in children may be lacking. As compared to adult dosing, pediatric dosing includes a component of safe dose ranges rather than a single, accepted dose. Some medications are, in fact, ineffective in children. Medication sensitivity in infants depends on many factors specific to their developmental phase and is not like medication sensitivity in adults.

Which health screening and immunization recommendations are appropriate for a 48-year-old client? Select all that apply. One, some, or all responses may be correct.

Pelvic examination annually Blood pressure at every visit but at least every 2 years Blood lipids every 5 years if blood cholesterol is within normal limits Measles, mumps, and rubella immunization once if born after 1956 with no evidence of immunity Rationale: A 48-year old female will need a pelvic examination annually, a blood pressure check at every visit (at least every 2 years), blood lipid measurement every 5 years if blood cholesterol is within normal limits, and the measles, mumps, and rubella immunization once if born after 1956 with no evidence of immunity. Blood cholesterol needs to be done only every 5 years or more often if a client has abnormal levels or risk factors for coronary artery disease. Pap and HPV testing should be done every 5 years between the ages of 30 and 65.

Which interventions would the nurse implement to prevent infection in a preschool child with acute nonlymphoid leukemia who is admitted with a fever and neutropenia?

Placing the child in a private room, restricting ill visitors, and using strict hand-washing techniques Rationale:Children with leukemia most often die of infection; a low neutrophil count is associated with myelosuppressant therapy. Placing the child in a private room, restricting ill visitors, and using strict hand-washing techniques are the best ways to minimize complications. Encouraging a well-balanced diet, including iron-rich foods, and helping the child avoid overexertion are not appropriate measures to prevent infection resulting from neutropenia; they are appropriate for treating the anemia. Avoiding taking rectal temperatures, limiting injections, and applying direct pressure for 5 minutes after venipuncture are not appropriate measures to prevent infection resulting from neutropenia; they are more appropriate for preventing bleeding. Offering a moist, bland, soft diet; using toothettes rather than a toothbrush; and providing frequent saline mouthwashes are not appropriate measures to prevent infection resulting from neutropenia; they are used to ease and treat stomatitis.

Which phase of disaster management occurs when the community health nurse in a community that is geographically vulnerable to storms teaches the community about safety measures to be taken during a storm?

Preparedness Rationale: Preparedness is the phase in which a plan is designed before the disaster event to best structure the response. Teaching safety measures to the people of a locality is the preparedness phase. The recovery phase involves stabilizing the community after a disaster event. Response is the implementation of the disaster plan. Mitigation is a phase of disaster management in which attempts are made to limit the disaster's impact.

The nurse is caring for a client with a bowel obstruction. Which assessment findings indicate the possible onset of peritonitis? Select all that apply. One, some, or all responses may be correct.

Rebound tenderness Diminished bowel sounds Rigid, boardlike abdomen Rationale: Classic signs of peritonitis include abdominal rebound tenderness, diminished or absent bowel sounds, and a rigid, boardlike abdomen. The client will experience constipation, not diarrhea. The heart rate will be tachycardic.

Which instructions to minimize the risk of falls in the home would the nurse provide the caregiver of an older client who requires the use of a walker with wheels? Select all that apply. One, some, or all responses may be correct.

Remove cords. Use bright lighting. Get rid of throw rugs. Rationale: The nurse would instruct the caregiver to remove cords, use bright lighting, and eliminate throw rugs to prevent falls. Bed alarms are used in health care facilities. Keeping the phone close by will allow the older adult to obtain help, but this action does not prevent falls.

Which actions by the nurse are appropriate when a fire breaks out at the hospital? Select all that apply. One, some, or all responses may be correct.

Removing clients from immediate danger Using a wheelchair to move an immobile client Directing ambulatory clients to walk to a safe location Rationale:According to the fire safety portion of the emergency response for internal disasters, the nurse would remove clients from immediate danger, use a wheelchair to move immobile clients, and direct ambulatory clients to walk to a safe location. The nurse would discontinue oxygen for clients who can breathe without it but not for all clients. The nurse would seek to contain the fire only after everyone is out of danger and there is no risk of injury to self or others.

Which clinical finding during labor induction requires the nurse to discontinue the oxytocin infusion?

Several late fetal heart rate decelerations that return to baseline after the contraction is over Rationale: Late decelerations suggest uteroplacental insufficiency, which is an indication that the oxytocin infusion should be stopped. Continuing the infusion may compromise the status of the fetus. Contractions that occur every 3 minutes and last 60 seconds are within acceptable parameters; they require continued monitoring, and the infusion of oxytocin may be continued. An increase in blood pressure from 110/70 to 135/85 mm Hg during the past 30 minutes or rupture of the membranes requires continued monitoring but does not make it necessary for the infusion of oxytocin to be stopped.

Which entity would the nurse consult as being ultimately responsible for the implementation of the plan to administer vaccines after an episode of pandemic influenza?

State officials Rationale: Each state has its own specific emergency preparedness plan for pandemic influenza, including who would receive vaccines in a mass casualty event. Local, federal, and hospital officials are not ultimately responsible for this emergency preparedness plan.

The nurse is caring for a client who underwent a total thyroidectomy. Which assessment finding would lead the nurse to notify the rapid response team?

Stridor Rationale: Stridor is an indication of respiratory distress, which would require immediate intervention from the rapid response team. Hoarseness is a normal postoperative finding. Tachycardia, not bradycardia, is a sign of respiratory distress. Hypocalcemia can be corrected with intravenous (IV) calcium gluconate or calcium chloride. The assessment finding that would lead the nurse to notify the rapid response team in a client who underwent a total thyroidectomy is Stridor. Stridor is a high-pitched, harsh sound that is heard during inspiration and indicates airway obstruction, which is a medical emergency that requires immediate intervention. Hoarseness is a common finding after thyroid surgery due to the proximity of the vocal cords to the thyroid gland and may not require rapid response team notification unless it is severe or accompanied by other symptoms. Bradycardia is a possible complication of thyroid surgery, but it does not require rapid response team notification unless it is symptomatic or associated with other significant changes in vital signs or symptoms. Hypocalcemia is a potential complication of thyroid surgery due to damage to the parathyroid glands, but it usually develops over time and does not require rapid response team notification unless it is severe or symptomatic.

A client with acquired immunodeficiency syndrome (AIDS) and cryptococcal pneumonia frequently is incontinent of feces and urine and produces copious sputum. When giving this client a bath, which protective equipment would the nurse use? Select all that apply. One, some, or all responses may be correct.

Surgical mask Gown Gloves Rationale: A gown, mask, and gloves when bathing the client prevent contact with feces, sputum, or other body fluids during intimate body care. Goggles would be important only if the client was on mechanical ventilation to avoid contact with sputum. Shoe covers are designed for protecting a sterile environment such as a surgery suite and are not necessary for giving client care at the bedside. An N95 HEPA mask would be necessary if the client had tuberculosis, but not for cryptococcal pneumonia alone.

The nurse is planning care for a client with hyperparathyroidism and subsequent hypocalcemia and low bone density. Which information would the nurse provide the unlicensed assistive personnel (UAP) to prevent injury?

Use a lift sheet for transfers. Rationale: Hypocalcemia leads to low bone density, which places the client at risk for pathological bone fractures. Therefore the nurse would instruct the UAP to be careful when moving the client and use a lift sheet for repositioning. Urinary output, respirations, and cardiac monitoring are important interventions, but not for preventing injury.

The nurse is caring for a client who had head and neck surgery. Which complication will the nurse try to prevent by positioning the client's head in functional alignment after surgery?

Wound dehiscence Rationale: Maintaining functional alignment of the head prevents flexion and hyperextension of the neck, both of which place tension on the suture line; tension on the suture line can precipitate wound dehiscence. The cervical vertebrae are designed to flex and hyperextend; there should be no ill effects. Flexion and hyperextension of the neck do not cause laryngeal spasms. Flexion and hyperextension of the neck do not cause laryngeal edema.

Which condition in a client with a brain injury is contraindicated for magnetic resonance imaging (MRI) with contrast?

Metal aneurysm clips Rationale: Any implanted metal is contraindicated to enter the MRI area because MRI machines use a powerful magnet. Renal failure is not necessarily a contraindication to MRI with contrast because the MRI contrast agent gadolinium is not nephrotoxic. Open MRI is an option for claustrophobic clients, although this type of imaging may not be a good as traditional MRI. Soft tissue is captured well by MRI—it is bone that is not well visualized by this form of imaging.

Which cardiac disease has the lowest risk for maternal mortality?

Patent ductus arteriosus Rationale: A client with patent ductus arteriosus has the lowest risk for maternal mortality. A client with aortic stenosis has a higher risk of maternal mortality. A client with endocarditis or pulmonary hypertension has the highest risk of maternal mortality.

Which is the priority nursing intervention for an infant with a myelomeningocele before surgical correction?

Preventing trauma to the sac Rationale: A myelomeningocele is thinly covered and fragile. Trauma to the sac can damage functioning neural tissue; an intact sac eliminates a potential portal of entry for microorganisms. Although minimizing infection is extremely important, it is not the priority; care of the sac is even more important, because an intact sac bars entry by microorganisms. Although observation for paralysis is an important nursing measure, it is not the priority. The open defect may make thermal homeostasis more difficult to maintain, but prevention of trauma to the sac is a higher priority.

Which factors would the nurse recognize as increasing the incidence of injury to a school-aged child? Select all that apply. One, some, or all responses may be correct.

The protection offered by adults The behavior patterns of the child Dangers present in the environment Rationale: The protection offered by adults, behavior patterns of the child, and dangers present in the environment affect the incidence of injury to a school-aged child. The physical activity level of the child or participation in extracurricular activities does not affect the incidence of injury to a school-aged child.