NCLEX-PN Safety and Infection Control

The nurse initiates sterile wound care on a clients newly debrided foot ulcer. After removing the dressing and beginning a betadine cleanse, the client mentions an allergy to iodine not previously reported. Place the nursing actions in order of priority. -Cover the wound with temporary sterile dressing -Remove betadine solution from wound with normal saline. -Ask client about the type of allergic response. -Observe client for signs or symptoms of reaction -Notify primary healthcare provider of the allergy.

-Cover the wound with temporary sterile dressing -Remove betadine solution from wound with normal saline. -Ask client about the type of allergic response. -Observe client for signs or symptoms of reaction -Notify primary healthcare provider of the allergy.

During night time rounds, the nurse finds a client has cigarettes in bed and the room is filled with smoke. In what order should the nurse perform the following actions? -Remove client from room -Pull fire alarm handle -Notify hospital operator -Close the client's door -Get the fire extinguisher.

-Remove client from room -Pull fire alarm handle -Notify hospital operator -Close the client's door -Get the fire extinguisher.

A farm worker comes into the clinic reporting headache, dizziness, and muscle twitching after working in the fields. What condition does the nurse suspect? 1. Pesticide exposure 2. Heat stroke 3. Anthrax poisoning 4. Gastroenteritis

1 These are symptoms of pesticide exposure when combined with the details given of coming from the fields. Death can result from severe acute pesticide poisoning.

While making rounds, the nurse discovers a small fire in a client's room. What should the nurse do first? 1. Remove the client from the room immediately 2. Leave the client's room to obtain a fire extinguisher. 3. Instruct the unlicensed personnel (UAP) to pull the fire alarm. 4. Evacuate all clients from the unit.

1 Rescue/remove the client; first step in rescue, alarm, contain, extinguish, (RACE)

The home health nurse is caring for a client who is identified as high risk for falls. What observations would indicate a therapeutic response to home fall prevention education? 1. Installs a grab bar in the tub 2. Turns night lights on at bedtime 3. Only use assistive devices when leaving home. 4. Goes barefoot while in the home. 5. Uses throw rugs in walking areas to prevent slipping. Select all

1 & 2 Placing a grab bar in a slippery tub can assist the client in getting into and out of tub. Turning on night lights at night ensures that the client can navigate safely, this reducing the risk of falls.

When disposing of waste in a client's room, the nurse would place which items in a biohazard red bag? 1. Chest drainage unit 2. Doxorubicin IV bag and tubing 3. Staples removed from an abdominal incision 4. Tramadol 50 mg tablet prescribed but refused by client. 5. Soiled dressing 6. Paper trash with identifying client information Select all

1 & 5 Chest drainage units should be capped and placed in a large red biohazard bag for disposal. Dressings soiled with human waste, blood or body fluids should be disposed of in a red biohazard bag.

1. A 48yr 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 post op 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. Select all

1 & 5 Both the client with a postop appendectomy and the client with nephrolithiasis will need frequent pain assessments. Also, neither client has an infection that could be transmitted to the other client. These 2 clients can be assigned to the same room. The clients with asthma and COPD are noninfectious respiratory diseases, so they also can be assigned to the same room.

A client diagnosed with brain injury continues to attempt to get out of the bed without assistance. Which interventions would the nurse implement? 1. Ask a familiar person to stay with the client. 2. Apply position change sensor to the bed. 3. Move client closer to the nurses station. 4. Reinstruct the client to not get out of the bed. 5. Provide positive and negative reinforcement. Select all

1, 2, 3 Having a person directly monitor the client will decrease the possibility of the client getting out of the bed. In addition, a familiar person in the room can have a calming effect on the client. Bed alerts will notify the healthcare team that the client is moving in the bed. This will result in a quicker response time to evaluate if the client is trying to get out of bed. The intervention of moving the client closer to the nursing station will increase the observation of the client. This increased visualization can allow the healthcare team to intervene if the client tries to get out of the bed.

The homecare nurse is reinforcing family teaching on safety issues for a client diagnosed with Parkinson's disease. What adaptations should the nurse emphasize for the family to initiate? 1. Install grab bars on tub walls 2. Place nightlights in hallways. 3. Add bran and fiber to daily diet. 4. Remove scatter rugs or loose cords 5. Keep bedroom dark , cool and quiet. 6. Put tennis balls on legs of walker. Select all

1, 2, 3 , 4 ,5 Parkinson's disease causes deterioration of the basal ganglia, ultimately impacting motor control and function. As muscles become stiff and rigid, mobility slows, resulting in poor coordination and loss of balance. Safety is a chief concern in all ADLs requiring modifications in activity , nutrition and the client's environment.

A nurse is planning an educational session on safety for parents of young children. What safety points should the nurse include? 1. Teach children the basics of swimming. 2. Plan an escape route in the event of fire. 3. Make sure that sand surrounds the playground. 4. Gates should be placed at the top and bottom of stairs when toddlers are present. 5. Vitamins should be referred to as candy so that children take them. 6. A child at age 7 may sit in the front seat of a car. Select All

1, 2, 3 ,4 Everyone should know the basics of swimming (floating, moving, through water) and cardiopulmonary resuscitation (CPR). Create and practice a family fire escape plan and involve kids in the planning. Make sure everyone knows at least two ways out of every room and identify a central meeting place outside. Falls on playgrounds are common and can cause serious injury. Wood chips or sand, not dirt or grass should be under playground equipment. Having a gate at the top and bottom of stairs can prevent falls.

A nurse is caring for a client diagnosed with the Ebola virus who is experiencing vomiting and diarrhea. What personal protective equipment should be worn by the nurse while providing care to this client? 1. Single-use impermeable gown 2. Powered Air Purifying Respirator (PAPR) or N95 respirator. 3. One pair of sterile gloves 4. Single-use boot covers 5. Single-use apron Select all

1, 2, 4, 5 The nurse should wear a single-use (disposable) impermeable gown OR a single-use impermeable coverall. Either a PAPR or a disposable. NOSH-certified N95 respirator should be worn to reduce the risk of contamination in the case of an emergency situation where a potentially aerosol-generating procedure would be performed. The PAPR reduces the risk of self-contamination while providing client care, but the N95 respirator is less likely bulky. If the N95 respirator is selected for use, nurses should be extremely careful to make sure that they do not accidentally touch their faces under the face shield during client care. Disposable boot covers should be worn and should extend to at least mid-calf. Some agencies may add the single use shoe covers over the boot covers to reduce the risk of contaminating the underlying shoes.

A client is seen in an outpatient clinic for anxiety after losing the family home in a hurricane. What actions would be appropriate for the nurse to make? 1. Reinforce teaching the client how to use progressive muscle relaxation. 2. Assist the client in correcting any distortion being experienced. 3. Suggest that the client might recover faster by moving away from the coastal area. 4. Refer the client to the family's primary healthcare provider for a complete physical examination. 5. Allow the client time to talk about the loss. Select all

1, 2,5 The correct answers are appropriate interactions for this client and will help the client with anxiety reduction. Allowing the client time to talk shows them that someone cares. Muscle relaxation helps relax the client. Helping the client see the situation accurately helps decrease a distorted view of the experience.

The nurse is providing teaching for a client who is being scheduled for outpatient 24 hour electrocardiogram monitoring using a Holter monitor. What should the nurse tell the client to avoid while monitoring is in progress. 1. Taking a shower or bath 2. Performing daily exercises 3. Working around high voltage equipment 4. Being screened at airport security. 5. Eating foods that are sources of potassium. Select All

1, 3, 4 The nurse should teach this client to continue the usual activities while wearing the monitor with a few exceptions. The monitor should be kept dry to ensure that it functions properly. The client should avoid taking shower or bath or swimming while wearing the monitor. The electrodes could also become detached from the skin if they get wet, which would also interfere with the accuracy of the reading. The client should be advised to not work around high voltage equipment because areas of high voltage can interfere with function of the electrocardiogram monitoring. In addition, magnetic fields, such as those used for airport screenings, can interfere with the function of the Holter monitor and should be avoided.

The client has the need for droplet precautions due to a respiratory illness. When providing care for this client, when is it appropriate for the nurse to wear a mask? 1. Performing tracheostomy care 2. Delivering mail to the client's room. 3. Bathing the client. 4. Feeding the client 5. Making routine room checks. Select All

1, 3, 4 The nurse will be in close contact with the client and may become contaminated by droplets from the client's respiratory tract. The client may cough while the nurse is feeding or bathing the client.

The nurse is preparing a client for transport to the radiology department for a left lung tissue biopsy. Which actions should the nurse make certain have been completed? 1. The consent form is signed. 2. The operative site is prepped with a razor. 3. The most recent lab work is on the chart. 4. Any preoperative medication is given as prescribed. 5. Person performing the procedure has marked the site. Select All

1, 3, 4 & 5 The nurse should ensure that the consent form is signed, the lab work is in order, and any prescribed preoperative medication is given. The preoperative site is marked by the person who is ultimately accountable for the procedure and will be present when the procedure is preformed.

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. Select All

1, 3, 4, 5, 6 The outer leaves of green leafy vegetables, such as lettuce and cabbage, should be discarded as pesticide residue likely remains there. Another great idea to reduce overall exposure to pesticides is to buy organic, peel fruits and vegetables prior to eating. Washing your fruits and vegetables is not enough if you want to reduce the pesticides 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. A scrub brush is very effective in cleaning the crevices and areas around the stem.

An unlicensed assistive personnel (UAP) enters the unit with artificial fingernails in place. What should the nurse explain to the UAP? 1. Pathogenic bacteria can be found on the fingertips of those who wear artificial fingernails. 2, Artificial fingernails are allowed to be worn on the unit. 3, Fungal growth can occur under the artificial fingernail, thus increasing the risk of infection to the client. 4. A more vigorous handwashing is required if artificial fingernails are worn. 5. Long fingernails and artificial fingernails increase microbial load on the hands. Select All

1, 3, 5 The variety and amount of pathogenic bacteria cultured from the fingertips of those wearing artificial fingernails is greater than from those with natural nails, both before and after handwashing. Fungal growth occurs frequently under artificial fingernails because moisture gets trapped between the natural fingernail and artificial fingernail, providing a medium for growth. Natural nails should be less than 1/4 inch long.

The nurse has completed newborn discharge teaching with the parents. Which statements by the parents would indicate accurate understanding of proper CPR for infants? 1. Place the infant on a firm, flat surface. 2. Use the palm of one hand to do compressions. 3. Give compressions at a rate of at least 1 per second. 4. Compress about one third the anterior-posterior diameter of the chest. 5. Give one breath after every 15 compressions. 6. Time to give breaths should not take longer than 10 seconds. Select All

1, 4 ,6 A firm surface is needed for compressions to be effective. Keep in mind, if the infant is small enough, the forearm, while holding the infant , can serve as the firm surface. The depth of compressions for infants should be approximately one third of the anterior posterior (AP) diameter of the chest, which is usually about 1 1/2 inches. Interruptions in compressions should be minimized when giving breaths and should be less than 10 seconds.

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 STI's Select All

1, 4, 5 ALL of these topics ahould be included when discussing prevention of STI's. Safe sex practices include proper use of condoms. Abstinence is the best way to prevent STI's. Vaccines are available for some STI's such as human papillomavirus vaccine (HPV).

A new nurse enters the linen room for supplies and finds a pile of sheets on fire. What type of fire extinguisher is most appropriate for the nurse to use in this situation? 1. Foam type 2. Water only 3. Dry powder 4. Carbon dioxide

1. A "water only" fire extinguisher is used for Class A fires which includes solid combustibles such as wood, paper and textiles. As long as no electric equipment is plugged into a socket in the room, the water-only extinguisher is most appropriate.

The nurse is observing a new LPN insert an indwelling foley catheter for a client. The nurse knows it is necessary to intervene when the new LPN initiates what action? 1. Applies sterile gloves prior to opening catheter kit. 2. Pours iodine solution over the sterile cotton balls. 3. Lubricates catheter by dipping into water-soluble gel. 4. Identifies client and elevates bed to waist height.

1. A catheter kit is removed from the plastic bag and opened up without any gloves at all. The use of sterile gloves would not be necessary and would be a waste of money as the outside of the kit is not sterile.

Which is the correct method for removing personal protective equipment (PPE)? 1. Contaminated gloves should be removed in the client's room. 2. The glove that is removed first should first be placed in the wastebasket before the other glove is removed. 3. Remove face shield or goggles first. 4. Shoe covers should be removed last.

1. Avoid contaminating self, others, or environment when removing equipment.

A new nurse is preparing an injection from an ampule. What action by the new nurse would require the precepting nurse to intervene? 1. Snaps the neck of the ampule gently towards the body. 2. Uses a filter needle when drawing up the ampule contents. 3. Folds gauze around the ampule neck before snapping open. 4.Avoids touching edges of the ampule when inserting needle.

1. An ampule is a glass vial with a narrow, scored neck that must be snapped off to open. Even if the neck of the ampule is covered with gauze, the proper procedure is to snap the top away from the body, not toward the body. If the new nurse attempts to snap the top of the ampule toward the body, the charge nurse would need to intervene immediately.

Which information should the nurse reinforce to family members of a client diagnosed with hepatitis B to decrease their risk of exposure? 1. Do not share personal items with the client , such as razors or toothbrushes. 2. Wash dishes in seperate water to decrease the risk of contamination. 3. Do not hug or kiss the client. 4. Use a separate bathroom from the client.

1. Hepatitis B is a bloodborne pathogen that can spread via sharing personal items, such as razors or toothbrushes.

The nurse is reinforcing the medication prescriptions with a client for which English is a second language (ESL). Which nursing intervention most likely will prevent a medication error with this client? 1. Use the teach-back method so that client is repeating the instructions back to the nurse. 2. Give printed information to the client. 3. Ask the client if they have questions before the client leaves the healthcare setting. 4. Refer medication questions to the pharmacist.

1. The teach-back method of asking the client to repeat the teaching instructions to the nurse will most likely reveal any misunderstanding. This allows the nurse to reinforce any areas where clarification is needed.

The charge nurse is observing a LPN/VN perform a dressing change on a client with a stage 3 pressure ulcer. What observation by the charge nurse would indicate a need for further teaching? 1. Irrigate the pressure ulcer with 50mL normal saline. 2. Irrigates the pressure ulcer with half -strength hydrogen peroxide. 3. Packs the wound with sterile gauze soaked in normal saline. 4. Applies a hydrocolloid dressing over the wound after cleansing.

2 Pressure ulcers should not be cleaned with substances that are cytotoxic such as hydrogen peroxide, betadine or Dakin's solution. Cytotoxic means toxic to cells, cell-killing. Any agent or process that kills cells. These solutions can kill or damage cells, especially fibroblasts. Dakin's solution is a type of hydrochloride solution. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine is the active ingredient in Dakin's solution.

A new mother asks the clinic nurses why her baby should receive recommended vaccinations. What is the best response by the nurse concerning vaccinations? 1. Vaccinations give antibodies to your baby to protect them from disease. 2.Vaccinations will help your baby produce antibodies against disease causing organisms. 3. Federal law requires that your baby receive recommended vaccinations. 4. There is no reason not to vaccinate your baby since only mild, uncomfortable reactions can occur.

2 Vaccines are suspensions of antigen preparations intended to produce a human immune response to protect the person from future encounters with the organism.

A client has been admitted with multiple severe allergies, including food and medications. The nurse knows what actions are most important to protect the client? 1. Assign client to a private, sterile room. 2. Place allergy alert bracelet on client. 3. Have client wear mask when in hallway. 4. Attach sign listing allergies above the bed. 5 Send list of allergies to dietary department. Select All

2 & 5 It is crucial to place the facility's allergy alert braclet on the client upon admission, generally on the same wrist as the facility ID bracelet. Each time the client's ID is verified, staff will also see the allergy bracelet. Dietary department must also be alerted to all allergies in writing as should the pharmacy. In most facilities allergy alert stickers are attached on the outside of the chart, on the medication sheet, and facility-specific areas to remind the staff caring for the client.

When explaining to caregivers how to reduce the risk of falls in their elderly parent , the nurse should educate about which measures? 1. Allow the parent to wear shoes that are most comfortable. 2. Assure there is adequate lighting with minimal glare. 3. Use sharply contrasting colors at edges of stairs. 4. Install grab bars beside the shower, tub, and toilet. 5. Encourage the parent to have an inside pet for comfort. 6. Rearrange the furniture for the parent to prevent stagnation.

2, 3, 4 Adequate lighting with minimal glare is best to assure there is the amount of illumination needed for safe mobility. Marking the edges of stairs with sharply contrasted colors can help to reduce falls by alerting the elderly client of the change in the elevation of the walkway. The risk of falls in the bathroom can be diminished by installing grab bars to help stabilize the elderly client as they make position changes or transition from the tub, shower, or toilet.

A nurse is working with community officials to decrease the incidence of violence in the community. Which primary preventive measures might the nurse suggest? 1. Provide a safe haven for victims of violence 2. Provide educational programs about types of violence 3. Form a neighborhood watch program 4. Develop a media campaign identifying risk factors of potential abuse. 5. Provide for the immediate removal of a victim of violence from the home. Select all

2, 3, 4 These are all appropriate interventions for the nurse to suggest to the community The key is prevention. The nurse is teaching ways to prevent violence before it occurs. Primary prevention is true prevention.

As a member of the emergency preparedness planning team at the hospital, which actions should the nurse encourage the team to implement? 1. Developing a response plan for every potential diaster. 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. Assessing all client care duties to the nursing supervisor. Select All

2, 3, 4 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.

A primary healthcare provider has prescribed restraints for a violent client. Which measures would the nurse provide as proper interventions for this client? 1. Observe the client in restraints every hour. 2. Ensure that circulation to extremities is not compromised. 3. Assist client with needs related to nutrition and elimination. 4. Provide help with personal hygiene. 5. Participate in a staff debriefing after the incident.

2, 3, 4 ,5 These are correct interventions for safety when a violent client requires restraints. When applying restraints you do not want the restraint so tight that extremity circulation is diminished. The client must still be provided with proper nutrition, hydration and allowed to go to the restroom . If the client will need help with basic care and comfort measures. It is essential that staff debrief after such an event to see what might have been done differently to de-escalate the clients violence.

What intervention should the nurse plan to implement when caring for a client diagnosed with measles? 1. Admit to a semi-private room with a client diagnosed with tuberculosis (TB) 2. Place a surgical mask on the client when transferring to x-ray. 3. Initiate airborne precautions 4. Wear surgical mask when entering the client's room 5. Assign a nurse who has received the measles vaccine to take care of this client. Select all `

2, 3, 5 If the client must leave the room, a surgical mask should be worn to prevent transmission to others. Measles can be transmitted via contact , droplet and airborne methods , so airborne precautions are needed. Healthcare providers who are not immune to measles should not care for a client with measles.

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. Select all

2, 4, 5, 6 Athletes foot is treated with topical antifungal in most cases. Severe cases may require oral drugs. The feet must be washed daily with soap and water and dried thoroughly since the fungus thrives in moist environments. Steps to prevent athletes foot include wearing shower sandals in public showering areas and wearing shoes that allow the feet to breathe.

The nurse is assisting a client with right-sided weakness to transfer from the hospital bed to a wheelchair. The client has an IV attached to an IV pole on the right side of the bed. How should the nurse complete this transfer? 1. Place the wheelchair on the left side of the bed. 2. Place the wheelchair on the right side of the bed. 3. Face the wheelchair toward the foot of the bed. 4. Face the wheelchair toward the head of the bed. 5. Have the client grab the wheelchair with the right arm. 6 Have the client grab the wheelchair with the left arm. Select All

2, 4, 6 The wheelchair should be placed on the right side of the bed where the equiptment is located. It needs to face the head of the bed so the client can reach the chair with the strong left arm to help with the transfer. The client should grab the wheelchair arm with the strong left arm.

The nurse is reinforcing information about car accident prevention to a group of high school students. Who would the nurse include as the highest risk for a motor vehicle crash (MVC)? 1. Males who have just turned 19 years of age. 2. Drivers who have recently acquired a driver's license. 3. A group of students that carpool to the senior prom 4. Female students who drive to weekly football games

2. According to the Centers for Disease Control and Prevention (CDC), crash risk is particularly high during the first year the teenagers are eligible to drive. Though teenagers who are 19 years old, carpooling to the senior prom, and driving to weekly football games are also at risk for an MVC, they are not the highest-risk n teenage group.

The nursing staff have not been able to control the outbursts of a violent adult client. The primary healthcare provider prescribes physical restraints to be applied for the next 8 hours. What is the nurse's best action? 1. Apply the restraints for the 8 hours, with a trial release every 2 hours. 2. Explain to the primary healthcare provider that the prescription will have to be reissued in 4 hours. 3. Refuse to place the client in restraints unless the primary healthcare provider gets a permit signed from the family. 4. Apply the restraints, and observe the client history.

2. Orders for restraints or seclusion must be reissued by a primary healthcare provider every 4 hours for adults age 18 and older, every 2 hours for children and adolescents ages 9-17, and every hour for children less than 9 years.

The nurse has just inserted an indwelling catheter into the hospitalized client. The nurse has cleared the items from the clients bed, has disposed of them, and has removed the gloves. What should the nurse do next? 1. Tidy the room 2. Wash Hands 3. Perform care for the other client in the room 4. Apply clean gloves and provide care to the other client in the room.

2. Standard precautions include washing the hands after removing gloves, and before performing other tasks.

The nurse is performing a chart audit for clients who were restrained. For which client would the side rails in the up position be considered a restraint? 1. The client who requests that the rails be placed in the up position 2. The client who is confused and wanders about the unit. 3. The client who is ambulatory and places the side rails up without staff assistance. 4. The client who asks the family to place all the rails up before leaving.

2. The intent of the side rails in the up position is to limit movement; therefore, they are considered a restraint. The nurse cannot restrain or limit a client's movement without a primary healthcare provider's prescription.

While programming the client's IV infusion pump the nurse notes that the display screen on the infusion pump is cracked. What is the best action for the nurse to take? 1. Continue to use the infusion pump and request a replacement pump. 2. Stay with the client and monitor the infusion while another staff member obtains a replacement pump. 3. Clamp and disconnect the infusion tubing prior to obtaining a replacement pump. 4. Slow the infusion to keep-open rate and obtain a replacement pump.

2. The safest action is to stay with the client while a new infusion pump is obtained by another staff member.

When the surgical transport team arrives to take a client to the operating room, the client is sitting in a chair in the room. What is the best way for the nurse to get the client onto the transport litter? 1. Using a foot stool, assist the client to step up and crawl onto litter 2. Have client return to bed and utilize slide board to transfer to litter. 3. With feet placed apart, grasp client around waist and lift onto litter. 4. Put Hoyer pad under client, using lift to move client from chair to litter.

2. The safest, most efficient manner by which to place the client on the litter properly is to have client first return to the bed. The bed can be raised to the height of the litter, allowing staff to utilize a slide board to easily position the client onto the litter. This method decreases safety risks for both staff and client.

The charge nurse is reviewing multiple events reported by staff during morning shift. The nurse is aware which event requires a written incident report? 1. Aclient yells loudly throughout the right shift. 2. A nurse discusses clients prognosis with family. 3. An unlicensed assistive personnel (UAP) spills water pitcher onto client. 4. A nurse tears sterile gloves and applies new gloves.

2. The purpose of an incident report is to document any incident report is to document any incident or usual event inconsistent with routine operations of hospital or staff routine and resulting in injury, or potential liability for clients family or staff.

The nurse is assessing the client's blood pressure using an electronic blood pressure machine and notes that the blood pressure reading is much higher than it has been since admission. The client denies history of hypertension. What action should the nurse take? 1. Call the primary healthcare provider and report the elevated blood pressure. 2. Check the blood pressure again in 4 hours and compare to the current blood pressure. 3. Re-check the blood pressure using a manual blood pressure cuff 4. Call the nursing supervisor and prepare for a possible hypertensive emergency.

3 Since the client does not have a history of hypertension and has not had elevated blood pressure since admission, the nurse should question the accuracy of the electronic blood pressure machine. Therefore, the nurse should re-check the BP using a manual cuff to determine if the high blood pressure reading was accurate.

The nurse working in a pediatricians office is teaching a couple with small children about proper medication administration for children. What statement by the couple would indicate that further teaching is needed? 1. We should carefully measure elixir medication with the provided dropper. 2. Our children should not watch us take medicine. 3. We tell our children the medicine is candy so they will take it without a fuss. 4. Even though medicine comes in a childproof container, we will put medication out of reach.

3 Calling medication "candy" is inappropriate and misleading to the child. Children may take medication to eat as candy if they have access to it...

A client admitted to a long-term care facility is legally blind and partially deaf. How would the nurse best provide for the client's safety in the event of an emergency? 1. Have roommate lead client out of the room to safety area. 2. Assign a specific UAP every shift to escort the client to safety. 3. Research established protocols utilized by emergency groups. 4. Discuss best communication methods with client and family. 5. Plan for the supervisor to be responsible for evacuating the client. Select all

3 & 4 When faced with a new or challenging situation involving client safety, the nurse manager should employ the nursing process to assess needs and collect contributing data. Asking for input from emergency preparedness groups, such as the Red Cross or FEMA, could provide ideas about assisting individuals with sensory deficits. Secondly, the nurse should discuss the situation with both client and family to determine appropriate methods of communicating with clients, particularly in an emergency situation.

A client being prepared for surgery is to be given a pre-operative medication, WHat is the nurse's priority action when administering the medication? 1. Verify client has signed all consent forms. 2. Escort the client to the bathroom to void. 3. Check that identification band is in place. 4. Raise side rails and put call bell in place.

3. All the actions mentioned are important, but the priority is client identification. Regardless of weather the nurse is administering medication, preparing the client to leave for surgery or for testing, the I.D. band must be in place during the entire hospitalization. If the band falls off or is removed for any reason, the client must be reidentified and banded before proceeding with any orders .

A school nurse is caring for a child who fell on the playground. Upon examination of the client, the nurse notes multiple bruises in various stages of healing. What is the nurse's initial intervention? 1. Ask the parents who hit the child on the back. 2. Notify the child's primary healthcare provider. 3. Contact the Department of Health and Human Services. 4. Document the findings and observe the child over the next week.

3. Unless there is a policy to direct otherwise, the nurse who suspects child abuse is obligated to report it to the Department of Health and Human Services (DHS)

A housekeeper has been called to the medical surgical unit to complete several tasks. Which tasks by the housekeeper has priority? 1. Replace the full sharps container in the medication room. 2. Clean room of discharged client who was isolated with MRSA. 3. Wipe up spilled coffee in the family room. 4. Repair a malfunctioning curtain around a clients bed.

3. When considering multiple safety issues, the priority is the situation which puts the greatest number of individuals at risk. Liquid on a floor is a fall hazard to anyone in that vicinity. A family waiting room has dozens of visitors a day, including adults, children, clergy, other staff and possibly other clients. The floor needs to be clean and dry to prevent injury.

The nurse is setting up the sterile field for the primary healthcare provider and another nurse to use. As the nurse and primary healthcare provider enter the room they don sterile gowns and gloves. As the procedure begins, the nurse observes that the other nurse in the room has turned her back on the sterile field. What should the observing nurse do first? 1. Nothing, as everyone is individually accountable for their practice. 2. Provide the nurse with another gown and sterile gloves. 3. Inform the primary healthcare provider and the nurse that the sterile field may have been compromised. 4. Remind the nurse not to turn back on a sterile field.

3. Anytime a nurse observes that the sterile field is compromised or may have been compromised , it is essential that it is reported to protect client.

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 100mL 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. Cellulitis is a bacterial skin infection resulting in warm, redden and edematous tissue, sometimes accompanied by fever and chills. Swelling in the affected area impedes blood flow and increases pain. In order to decrease the edema , warm, moist compresses are used to stimulate circulation and speed reabsorption of the fluid within the tissue. This order should be questioned immediately.

A client is brought to the emergency room following a serious motor vehicle accident. Standing orders include initiating an IV line and inserting a foley catheter. What action should the nurse take first? 1. Obtain all supplies for the procedures. 2. Explain the procedure to the client. 3. Check the client's identification band. 4. Verify client has signed consent forms.

3. Even in an emergency, the nurse follows the nursing process by initially gathering data, including identifying the client before beginning any ordered interventions. The client's identity must always be verified before any procedure or treatment.

The nurse is observing the work of an unlicensed assistive personnel (UAP). Which observation will require the nurse to intervene? 1. Placing soiled linen in a hazardous waste linen bag outside of the client's room. 2. Shutting the door completely when exiting the room of a client diagnosed with tuberculosis. 3. Wearing the same pair of gloves to collect intake and output reports from multiple clients. 4. Cleans a blood pressure cuff with a disinfectant.

3. Gloves should be removed and hand hygiene performed after leaving each clients room. Gloves quickly become contaminated and then become a potential vehicle for the transfer of organisms between clients. Standard precautions should be implemented.

What information should be reinforced when an 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 stick than HIV. 4. Neither virus is transmitted via body fluids.

3. Hepatitis B virus (HBV) and HIV can be transmitted in similar ways, but hepatitis B is more infectious. Studies show hepatitis B is more infectious. Studies show hepatitis B is more readily transmitted via needle sticks than HIV. More than 1 million people currently have HIV in the US. Hepatitis B is 50-100 times more infectious than HIV.

When preparing to administer the client a dose of intravenous piggyback (IVP) antibiotics, the nurse notes that the IV pump cord is frayed with wiring visible. What priority action should the nurse take? 1. Notify maintenance to come and check the pump immediately 2. Continue to use the IV pump and fill out an equipment maintenance request. 3. Obtain a replacement pump. 4. Tag the equipment for maintenance.

3. Removing potentially hazardous equipment is priority. Continued use of a faulty IV pump could lead to client endangerment such as electrical shock or fire.

A client has been diagnosed with genital herpes. Which comment indicates understanding of the disease and prevention of the spread of the disease? 1. I can be treated and then no one else is at risk. 2. Using condoms will keep my sex partner from acquiring the disease. 3. If I have no sores , I am not contagious to anyone. 4. My sex partner should be tested because we have not always used condoms.

4 The sex partner may become infected even if using a condom. The condom does not always cover all lesions. Condoms do, however, reduce the likelihood of getting/transmitting the disease.

How should the nurse assist a post-operative client in transferring from the bed to a chair? 1. Have the client look down and watch their feet as they move. 2. Tell the client to bend at the waist to lower the center of gravity. 3. Place a walker away from the bed so the client can lean forward while standing. 4. Ensure the client's feet are as wide apart as the hips.

4 This maintains the client's horizontal center of gravity.

A client with cervical cancer received an internal cervical radiation implant. What should be the initial nursing action if the radiation implant becomes dislodged and is found lying in the bed? 1. Call the client's primary healthcare provider. 2. Pick up the implant immediately with gloved hands and place it in double biohazard bags. 3. Notify the radiology department. 4. Utilize long-handled forceps to pick up the implant and dispose of it in a lead container.

4 If a client is receiving a radiation implant, a lead container and long-handled forceps should be placed in the clients room and kept for the duration of the therapy. If the implant becomes dislodged, the nurse should pick up the implant with long-handled forceps and place it in the lead container.

An unlicensed assistive personnel (UAP) is asked to transfer a client with left hemiplegia from the bed to a wheelchair. The nurse tells the UAP the safest approach for this transfer is what method? 1. Lift client from edge of bed, supporting under arms and pivot to chair. 2. Utilize a slide board to transfer client from bed to the wheelchair. 3. Apply nan ambulation belt around client's waist and pull into the chair. 4. Use a mechanical lift to move client from the bed into the wheelchair.

4 When transferring a large physically impaired client out of bed to a wheelchair, safety for both staff and client is most important. The UAP should use a mechanical lift, first rolling the client onto the sling, attaching the lift loops, and allowing the machine to do the work of lifting the client. This provides a safe, gentle lift for the client and protects the UAP from injury.

A client is admitted with irritable bowel syndrome (IBS) and shingles. The nurse is discussing the client assignments with the charge nurse. Which staff member should not be assigned to this client? 1. The nurse with a history of roseola. 2. The unlicensed assistive personal (UAP) with no history of roseola. 3. The UAP with a history of chicken pox. 4. The LPN/VN wit no history of chicken pox.

4. A nurse who has not had chicken pox could contract it and should not be assigned a client with shingles. Those who have not developed antibodies to the varicella zoster virus are susceptible to chicken pox. Chicken pox and shingles are both from the varicella virus.

A child who fractured the ulna and radius following a fall is experiencing itching under the cast. What would be an appropriate nursing intervention to help alleviate itching? 1. Apply a small amount of hydrocortisone cream with a cotton tip applicator, 2. Use a soft, sterile, cotton tip applicator to gently rub area under cast. 3. Apply warm, dry heat to the outside of the cast with a lightweight heating pad. 4. Circulate air under the cast utilizing a blow dryer on the cool setting.

4. Acceptable , safe way to try to alleviate itching is to use a blow dryer on the cool setting to circulate air under the cast. This is the only safe option provided.

What personal protective equipment should the nurse wear into the room of a client who has been placed on droplet precaution? 1. Gloves 2. Gown 3. Goggles 4. Mask

4. For a client on droplet precautions a facemask is worn for close contact with the client.

At a well-baby check the parents of a 14 month old report how the child is doing and then excitedly share that they have purchased and are moving into a fixer-up home that was built in the mid- 1960's. Based on the parents report, what would be the priority concern for the nurse to address with the parents? 1. Fall risk due to increased mobility 2.Increased anxiety due to change in the environment 3. Speech consisting of only 4 words. 4. Potential for lead poisoning.

4. Since the home that they are moving into was built before 1978, there is a high likelyhood that it has lead-based paint.

The LPN is caring for a four month old infant diagnosed with respiratory syncytial (RSV) and placed in contact isolation. What personal protection equipment (PPE's) should the LPN use when providing care to the baby? 1. Double glove when changing the infants 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. The main concern is to prevent the spread of the infection, which is transmitted by respiratory secretions. This baby would still be bottle fed and require burping. The potential exists for oral secretions from burping, or even spitting up, to contaminate the LPN'S uniform. Without a gown or mask, these secretions would be transmitted to other clients to whom the LPN provides care.

Two cognitively impaired siblings are clients in the same hospital room. During rounds, the nurse notes they have removed identification bands. Because of similar apperance, the nurse is unable to identify the correct client for blood work. What would be the most reliable method for the nurse to use to properly identify these clients? 1. Draw blood to type and crossmatch and compare with chart. 2. Call the primary healthcare provider to identify each client. 3. Ask nurses on the next shift to try to identify the clients. 4. Notify the family to come in and identify clients in person.

4. The only way to definitely identify a client with no identification bracelet who is unable to identify self is to have immediate family verify the client in person. When the family member arrives and verifies the client, the hospital must apply a new ID bracelet in the presence of the family for added security.

A school-aged child is being admitted for probable viral meningitis. What arrangements does the nurse need to make in order to prepare for this client? 1. Private room 2. Negative air-flow room 3. Droplet precautions including mask. 4. Needs standard precautions only.

4. Viral meningitis is caused by a group of enteroviruses, such as those that also cause mumps or measles. School-aged clients generally fare better than very young children or infants. The Center for Disease (CDC) has determined that standard precautions are adequate for older children and adults.

While preparing an information sheet for a client diagnosed with vancomycin resistant enterococcus (VRE) urinary tract infection (UTI), the home health nurse should include which instructions? 1. Wash hands with hot water and soap when hands are soiled. 2. Gloves are not needed in the home since contamination with VRE has already occurred. 3. Wash hands before using the bathroom and after preparing food. 4. Clean the bathroom and kitchen with warm water and bleach.

4. Clean the kitchen and bathroom with warm water and bleach to decrease contamination. The client should wash hands after using the bathroom and before preparing food.

The nurse observes a primary healthcare provider removing gloves after performing an invasive procedure on a client, and then entering another client's room without washing hands. What should be the nurse's action? 1. Ignore it since the primary healthcare provider knows best. 2. Contact the nursing supervisor. 3. Notify the chief of medical staff. 4. Remind the primary healthcare provider of the importance of standard precautions.

4. The nurse is the advocate and can remind the primary healthcare provider of the importance of washing hands before entering a client's room.