passpoint health promotion

A nurse is supervising a new graduate registered nurse who is caring for a client hospitalized with active tuberculosis (TB). Which action by the new graduate requires the nurse to intervene? A box of tissues is brought to the client from the supply room. A surgical face mask is applied before entering the client's room. A sputum culture is collected, labeled, and taken to lab as ordered. Hand washing is performed before entering the client's room.

2 A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the client's room because the HEPA mask can filter out 100% of small airborne particles. All of the other interventions are correct and appropriate for the nurse to perform. Remediat

A client with Meniere's disease is having an attack of vertigo. Which nursing intervention is the priority? Instruct the client to remain in bed. Use pillows to support the client's head. Remind the client to ask for assistance when turning. Assist the client to the restroom every hour.

2 The priority intervention is to have the client remain in bed to prevent falls. The other options are correct; however, client safety is the priority.

The nurse is precepting a graduate nurse and preparing to give infant immunizations. The preceptor asks the graduate, "Infant injections should only be given in which muscle?" What is the best response by the graduate nurse? "gluteus maximus" "deltoid" "vastus lateralis" "rectus femoris"

3 The vastus lateralis muscle is preferred until the deltoid muscle has developed adequate mass (approximately age 36 months). Medications are injected into the bulkiest part of the vastus lateralis thigh muscle, which is the junction of the upper and middle thirds of this muscle. The vastus lateralis is the preferred site for IM injection in infants under 12 months of age. The rectus femoris, and gluteus maximus sites are not developed as an infant.

A nurse administers incorrect medication to a client. After assessing the client, and completing an incident report, which is the priority action by the nurse? Complete an adverse drug reaction (ADR) report. Report the incident to the nursing regulatory agency. Anticipate suspension from the facility due to the error. Report the incident to risk management.

4 The incident should be reported to risk management in order to evaluate care, and determine potential risks or system problems that contributed to the error. This type of error will not be reported to the nursing regulatory agency, or result in the nurse's suspension. Some facilities track the number of errors made by a nurse, or that occur on a particular unit, in order to provide appropriate education, and to improve the nursing process. Adverse drug reaction forms are used to report a client's reaction to a medication, not errors.

The treatment team plans to place a client in full leather restraints. What is the best care for this client? Remove the leather restraints 2 hours Remove the leather restraints every 10-15 minutes Remove the leather restraints every 60 minutes Remove the leather restraints every 30 minutes

2 The nurse must check the client's circulation every 10 to 15 minutes because blood vessel damage, as well as skin and nerve damage, can occur within 15 minutes. Checking every 30 or 60 minutes is not often enough and could result in permanent damage to the client's extremities. Range-of-motion exercises should be performed every 2 hours.

A nurse assesses a client with psychotic symptoms and determines that the client likely poses a safety threat and needs vest restraints. The client is adamantly opposed to this. What would be the best nursing action? Contact the physician and obtain necessary orders. Restrain the client with vest restraints. Ask a family member to come in to supervise the client. Apply wrist restraints instead of vest restraints.

1 If a nurse feels that a client needs to be restrained, the nurse should inform the physician and obtain necessary orders. The nurse should also discuss this with the client's family members and ask their opinion. Applying a wrist restraint instead of a vest restraint is inappropriate if a vest restraint is genuinely necessary. It would be inappropriate to delegate this aspect of care to a family member.

Which prescription is entered correctly on the medical record? fentanyl 50 micrograms given IV every 2 hours as needed for pain greater than 6/10 give 4 U regular insulin IV now 0.5 mg MS given IM for c/o pain 60.0 mg ketorolac tromethamine given IM for c/o pain

1 Prescriptions should be written clearly to avoid confusion or misinterpretation. Clearly written prescriptions do not use a "trailing" zero (a zero following a decimal point) and do use a "leading" zero (a zero preceding a decimal point). Additionally, the prescribed medication should be written in full and avoid abbreviations of the drug and the dosage, such as "morphine sulfate" (avoiding use of "MS") and "micrograms" instead of "mcg."

A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first? Institute isolation precautions. Begin an I.V. infusion of dextrose 5% in half-normal saline solution at 100 ml/hour. Obtain a nasopharyngeal specimen for reverse-transcription polymerase chain reaction testing. Obtain a sputum specimen for enzyme immunoassay testing.

1 SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. Contained in airborne respiratory droplets, the virus is easily transmitted by touching surfaces and objects contaminated with infectious droplets. The nurse should give top priority to instituting infection-control measures to prevent the spread of infection to emergency department staff and clients. After isolation measures are carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-normal saline and obtain nasopharyngeal and sputum specimens.

A nurse practitioner (NP) orders an antibiotic to which the client is allergic. The nurse preparing the medication notices the allergy alert and contacts the NP by phone. The NP does not return the call and the first dose is due to be given. Which action by the nurse is the best solution? Hold the medication until speaking with the NP. Call the pharmacist and discuss a substitution for the medication. Ask if the client is really allergic to the medication. Give the medication as ordered by the NP.

1 The nurse must speak to the NP and review the order. The other answers are incorrect because the nurse is aware of a stated allergy and must not give a medication that can cause an allergic reaction. The pharmacist cannot prescribe a new medication.

A nurse is assigned to a client with a cardiac disorder. The nurse should question an order to monitor the client's body temperature by which route? rectal tympanic oral axillary

1 When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take temperature. Using this route could stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. The other options are appropriate routes for measuring the temperature of a client with a cardiac disorder.

The nurse finds a small fire in the linen closet. Which action(s) should the nurse take to minimize the consequences of the fire? Select all that apply. Contain the fire. Rescue clients who are at risk. Activate the alarm. Use a fire extinguisher. Step on burning embers to extinguish them. Leave closet door open to facilitate access to the fire.

1-2-3-4 RACE is an acronym used to remember these actions in the case of a fire. Rescue: assist anyone in immediate danger and help get them to a safe area as fast as possible. Alarm: alert others by activating any available alarm system. Contact 911 to report the location of the fire and alert on-site personnel. Contain: confine the fire as soon as possible by closing windows and doors behind you during evacuation. Extinguish: only attempt to put out the fire if it is small, if you have the proper equipment, and if it is safe to do so yourself. Retrieve the nearest fire extinguisher and follow the "P.A.S.S." procedure:P = Pull the pin breaking the plastic sealA = Aim at the base of the fireS = Squeeze the handles togetherS = Sweep from side to side. The nurse should not stamp on burning embers to try to extinguish them, as they may ignite the nurse's clothing. The nurse will need to complete an incident report, but only after the fire has been dealt with.

The nurse working at an allergy clinic is taking a health history on a client suspected of having allergic rhinitis. What would the nurse anticipate the client to report? Select all that apply. impairment of daily activities hyposomnia sleep disturbances paresthesia headache otalgia

1-2-3-5 The client with allergic rhinitis will report impairment of daily activities, hyposomnia, and sleep disturbances due to the symptoms they are experiencing. A headache is a symptom of allergic rhinitis. Paresthesia is a sign of peripheral damage. Otalgia is an earache.

Bacterial conjunctivitis has affected several children at a local day care center. A nurse should advise which measure to minimize the risk of infection? Set up a conference with the parents of each child to explain the situation carefully. Perform thorough hand washing before and after touching any child in the day care center. Close the day care center for 1 week to control the outbreak. Restrict the infected children from returning for 48 hours after treatment.

2 Bacterial conjunctivitis is very contagious. Attention should be paid to thorough hand washing, a major means of stopping the transmission of the disease. Closing the day care center for 1 week is not necessary because thorough hand washing will stop the spread of the infection. Keeping the children out for 48 hours is not necessary. A child may return to day care after being treated for 24 hours. Although the parents of each child should be told about the outbreak, doing so will not help to curtail or prevent the spread of the infection.

The client has various sensory impairments associated with type 1 diabetes. The nurse determines that the client needs further instruction when the client makes which statement? "I will carefully test the temperature of my bathwater." "I will avoid kitchen activities." "I will avoid hot water bottles or heating pads." "I will inspect my skin daily for pressure points and injury."

2 Safety concerns are essential for a client with sensory impairment. Water temperature should be tested carefully, hot water bottles should be avoided, and the skin should be inspected regularly. Independence and self-care are also important; the client should not be instructed to avoid kitchen activities out of fear of injury.

A nurse is transferring a client from the bed to a chair. Which action should the nurse take during this client transfer? Position the head of the bed flat. Help the client dangle his legs. Stand behind the client. Place the chair facing away from the bed.

2 After placing the client in high Fowler's position and moving the client to the side of the bed, the nurse should help him sit on the edge of the bed and dangle his legs. The nurse should then face the client and place the chair next to and facing the head of the bed.

An adolescent client is having surgery to repair a fractured left femur. As a part of the preoperative safety checklist, what should the nurse do? Ask the teen to point to the surgery site. Verify that the site, side, and level are marked. Ask the parents if they have signed the operative permit. Restate the surgery risks to the parents.

2 As part of a surgery safety checklist, the nurse must verify that the site, side, and level are marked. Pointing to the area is not sufficient identification of the surgery site. The nurse must verify the form has been signed by reviewing the form. The surgeon holds primary responsibility for explaining the risks of surgery.

The nurse is caring for a toddler who is visually impaired. What is the most important action for the nurse to take to ensure the safety of the child? Avoid startling the child by limiting excess noise. Maintain a tidy environment around the child. Request that the parent stay with the child. Use visual aids to facilitate communication.

2 Children with visual impairment explore the environment by feel. A tidy and organized environment can support this and promote the child's safety. It is a priority to make sure all items that could potentially injure the child are removed from the environment. This includes meal trays and supplies for procedures. It is not reasonable to expect the parent to be available at all times or to expect the parent to take on the nurse's responsibility. Visual aids won't be effective for a child with visual impairment. While limiting noise volume is helpful to avoid startling the child, this does not promote safety as effectively as establishing and maintaining an environment free of dangerous objects and obstacles.

A client is being discharged from same-day surgery. Which statement indicates that the client does not understand postoperative instructions about transportation to home? "My husband is taking the day off from work to drive me home." "I can drive myself home after surgery." "I am taking a taxi home, and my daughter will meet me at home." "My son will be here at noon to take me home."

2 The client admitted for same-day surgery should not drive home after the surgical procedure because it is unsafe. Even without an anesthetic, the surgical event can be more stressful than anticipated. It is acceptable to have someone arrive after the surgery has started to take the client home. A taxi is permissible but not desirable.

When assisting a community after a hurricane, the nurse determines that the community members are in the disillusionment phase of disaster recovery. What is the most appropriate intervention by the nurse when working with individual members? Remind them that they are lucky to be alive. Encourage them to verbalize their feelings. Encourage them to contact family members Remind them that everyone is doing the best they can.

2 The most appropriate action by the nurse is to encourage the individuals to verbalize their feelings. Once the nurse has allowed the person to verbalize their feelings, it may be appropriate to ensure the individual has additional supportive people with whom to talk such as family members. Reminding the person that everyone is doing their best closes off therapeutic conversations between the individual and the nurse. Telling survivors that they should be grateful that they are alive also closes off therapeutic communication

A nurse is administering a newly prescribed I.V. antibiotic to a client who suddenly develops wheezing and dyspnea. Which is the nurse's priority action? Administer epinephrine I.M. Discontinue the antibiotic infusion. Administer diphenhydramine I.V. Start 100% oxygen using a nonrebreather mask.

2 The nurse should first discontinue the antibiotic because it is the most likely cause of the allergic reaction. Next, oxygen should be administered followed by administration of epinephrine and/or diphenhydramine as ordered.

The nurse from the previous shift identified a client as a high risk for falls. The oncoming nurse finds the client on the floor at the beginning of the shift. The nurse assesses the client and notes no injuries. What is the best action by the nurse? Assist the client to a comfortable position on the floor, and ensure the call light is in reach. Place a fall-risk alert sign outside the client's room, and then notify the next of kin. Notify the health care provider, and document the fall in the chart, including location, injuries, the fact the health care provider was notified, and any changes to the care plan. Complete an incident report on the previous shift for allowing the fall, and then reassess the client's fall-risk level. Move the client to a safe position, and modify environmental factors that could have contributed to the fall. Documentation is unnecessary as no injuries occurred.

2 The nurse should notify the health care provider, then document the facts related to the fall, such as the location of the fall, health care provider notification, injury (if any), and necessary follow-up or changes in the care plan that occurred as a result of the fall. If an injury was present the client should remain where the fall occurred; however, if no injuries are noted the client should be assisted off the floor. The nurse should not include information that places blame on other health care members. The fall must be reported even if the client does not suffer an injury. Documentation of the incident in the client's chart is required.

A nurse is teaching accident prevention to the parents of a toddler. Which instruction is appropriate for the nurse to tell the parents? A bike helmet is needed once you remove training wheels. Place toxic substances out of the child's reach. Teach the toddler water safety. Don't allow the toddler to use pillows when sleeping.

2 Toddlers are extremely curious and explore everything. They are unable to differentiate between harmful and good substances. The parents should place all toxic substances, including detergent pods, up high where toddlers cannot reach them. If the child is a climber, then installing child safety locks on cabinets would be appropriate. Toddlers lack the cognitive development to understand water safety, but parents should adhere to all safety rules whether the child is in the bathtub or a swimming pool. The child should never be alone around water. Pillows shouldn't be placed in the crib of an infant, because they present the risk of suffocation, but they may be used by toddlers. Toddlers, depending on their age and agility, can ride small bikes with training wheels. They should always wear helmets because they are at risk for falling.

The nurse administers prednisone to a preschool child with nephrosis. What should the nurse do to ensure that the nurse has identified the child correctly? Select all that apply. Compare the room number on the bed with the number on the client's identification band. Verify the date of birth from the medical record with the date of birth on the client's identification band. Ask another nurse to confirm that this is the correct dose and correct client for whom the prednisone has been prescribed. Ask the parent to state the client's full name. Check the child's identification band against the medical record number.

2-4-5 The nurse should use at least two sources of identification before administering medication to any client. The identification can include the medical record number and the client's date of birth. It is not necessary to check the client and dose for this drug with another nurse. It is also not safe to use the room number or bed number as a source of identification as clients' locations in the hospital are frequently changed. A parent may be used as additional safety check with very young children because the nurse cannot assume that the child will give a correct first name.

While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. The nurse should first: assist the client back to bed. ask what the client was doing out of bed. assess the client's current condition and vital signs. activate the "Emergency Response" button.

3 The nurse's first priority is to complete an assessment of the client including assessment of airway, breathing, circulation, and vital signs as well as any change in level of consciousness or obvious injury.The nurse should not move the client or assist the client back to bed until after an assessment has been completed to prevent further injury.While it may be helpful to know what the client was doing out of bed in order to assess for potential confusion, the client's immediate safety is first priority.The nurse would not activate the "Emergency Response" button until an initial assessment was done to determine the need.

A client has a history of macular degeneration. What is the priority nursing goal while the client is in the hospital? Provide education regarding community services for clients with adult macular degeneration (AMD). Provide health care related to monitoring his eye condition. Promote a safe, effective care environment. Improve vision.

3 AMD generally affects central vision. Confusion may result related to the changes in the environment and the inability to see the environment clearly. Therefore, providing safety is the priority goal in the care of this client. Educating him regarding community resources or monitoring his AMD may have been done at an earlier date or can be done after assessing his knowledge base and experience with the disease process. Improving his vision may not be possible.

Bacterial conjunctivitis has affected several children at a local day care center. A nurse should advise which measure to minimize the risk of infection? Close the day care center for 1 week to control the outbreak. Restrict the infected children from returning for 48 hours after treatment. Perform thorough hand washing before and after touching any child in the day care center. Set up a conference with the parents of each child to explain the situation carefully.

3 Bacterial conjunctivitis is very contagious. Attention should be paid to thorough hand washing, a major means of stopping the transmission of the disease. Closing the day care center for 1 week is not necessary because thorough hand washing will stop the spread of the infection. Keeping the children out for 48 hours is not necessary. A child may return to day care after being treated for 24 hours. Although the parents of each child should be told about the outbreak, doing so will not help to curtail or prevent the spread of the infection.

Which topic would be most important to include when teaching the parents how to promote overall toddler development? Language is the most important achievement. Discipline is critical to appropriate development. Safety is a priority concern for this age group. Eating habits that follow into adulthood begin now.

3 Because of toddlers' high energy and poor impulse control, safety is a priority concern for this age group. Language is important in toddler development, but not the most important at this time. While parents should set clear guidelines for behavior, the priority for toddlers is ensuring safety. Diet habits should be developed at this time, but the most important subject to teach parents of toddlers is safety.

A nursing instructor is instructing a group of new nursing students. The instructor reviews that surgical asepsis will be used for which procedure? colostomy irrigation instilling eye drops IV catheter insertion nasogastric tube irrigation

3 Caregivers must use surgical asepsis when performing wound care or any procedure that involves entering a sterile body cavity or breaking skin integrity. To achieve surgical asepsis, objects must be sterilized or kept free of all pathogens. Because inserting an IV catheter disrupts skin integrity and involves entry into a sterile cavity (a vein), surgical asepsis is required. Medical asepsis is used when instilling eye drops. The GI tract isn't sterile; therefore, irrigating a nasogastric tube or a colostomy requires only clean technique.

A nurse is working on a labor and delivery unit that requires all visitors to pass a screening protocol prior to entry. What is the nurse's priority action when a person gains access to the unit after bypassing the screening protocol? Call security personnel to remove the visitor. Check to make sure each neonate is with its parent. Stop the visitor, and ask for identification. Note the time and a detailed description of the individual.

3 Labor and delivery units are locked to prevent neonate abduction. All visitors should be stopped at the door, identified, and matched to a current client. If an unidentified visitor gains entry without having gone through this process, it is appropriate to stop the person to ask for identification and confirm who the visitor is there to see. Calling security, making sure that each neonate is with its parent and noting the time and a description of the individual would not be the priority actions in this case; but rather what one would do for an attempted abduction.

An alarm signals, indicating that a neonate's security identification band requires attention. The nurse responds immediately and finds that the parents removed the identification bands from the neonate. Which action should the nurse take next? Reprimand the parents for allowing the identification bands to come off. Replace the identification bands. Compare the information on the neonate's identification bands with that of the mother's, then reattach the identification bands to one of the neonate's extremities. Obtain the neonate's footprints and compare them with the footprints obtained at birth.

3 The nurse should immediately compare the information on the mother's identification band with that of the neonate's and then reattach the neonate's bands. This safety practice prevents infant abduction. Replacing the bands without first verifying identification is irresponsible. Reprimanding the parents will be detrimental to the nurse-parent relationship. The nurse isn't qualified to compare footprints.

A parent calls the health clinic and tells the nurse that the toddler was found with an open and empty bottle of acetaminophen. The parent asks the nurse what to do. What is the nurse's priority intervention? Have the parent give the child syrup of ipecac. Tell the parent to get the child to drink a glass of milk. Give the parent instructions on how to call poison control. Determine whether the parent knows cardiopulmonary resuscitation (CPR).

3 The parent should call poison control and ask what immediate steps should be taken to treat this ingestion. Home administration of syrup of ipecac is no longer recommended. Milk is not an antidote for acetaminophen toxicity. Asking about CPR is not appropriate since it would distract from the immediate interventions needed.

When developing the teaching plan for a client who uses a walker, which principle should a nurse consider? The hand bar of the walker should be well below the client's waist. A standard walker needn't be picked up when moved. If one leg is weaker than the other, the walker and the stronger leg should move, together, approximately 6″ ahead of the body. The client's weight is supported by his weaker leg. When maximum support is required, the walker should be moved ahead approximately 6″ (15 cm) while both legs support the client's weight.

3 To prevent falls, a client who needs maximum support should move the walker ahead approximately 6″. The client's legs should bear the weight of his body. The hand bar of the walker should be level with the client's waist, not below it. If one leg is weaker than the other, the walker and the weak leg move together while the stronger leg bears the client's weight. To use a standard walker correctly, a client should pick it up to move it. However, some walkers have wheels and can glide across the floor.

The nurse administers an antipsychotic drug to a client with acute mania. The client still refuses to lie down on her bed, pushes other clients in the hallways, and screams threatening remarks to the staff. What should the nurse do next? Follow the client and ask her to calm down. Tell the client to lie down on the sofa in the community room. Seclude the client and use restraints if necessary. Tell the staff to ignore the client's remarks.

3The client is visibly out of control, and other measures have not helped. Therefore, the nurse needs to seclude the client and use restraints if necessary to protect the client and others from harm. Following the client and asking her to calm down or telling the client to lie down on the sofa is not helpful because the client's level of anxiety is too high for her to attempt to calm down on her own and she cannot control her behavior. Telling the staff to ignore the client's remarks is not helpful because the client needs external means of control to protect the client, other clients on the unit, and the staff. Safety is the priority.

Which nursing intervention is appropriate for a client with an arm restraint? applying the restraint loosely to prevent pressure on the skin tying the restraint to the side rail positioning the restrained arm in full extension monitoring circulatory status every 2 hours

4 A nurse must assess the circulatory status of a restrained extremity every 2 hours to prevent circulatory impairment. To make sure the restraint is secure without compromising the circulation, the nurse should leave approximately one fingerbreadth between the restraint and the extremity. Tying a restraint to the side rail or an immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. The restrained arm or leg should be flexed slightly to allow joint movement without reducing the effectiveness of the restraint.

A client found sitting on the floor of the bathroom in the day treatment clinic has moderate lacerations on both wrists. Surrounded by broken glass, the client sits staring blankly at the lacerations. What is the most important action for the nurse to take toward the client? Enter the room quietly and move next to the client to assess the injuries. Call for staff back-up before entering the room and restraining the client. Sit quietly on the floor next to the client. Approach the client slowly while speaking in a calm voice, calling the client by name, and saying that the nurse is there to help.

4 Ensuring the safety of the client and the nurse is the priority at this time. Therefore, the nurse should approach the client cautiously while calling the client's name and talking in a calm, confident manner. The nurse should keep in mind that the client shouldn't be startled or overwhelmed. The nurse should state a desire to help and should carefully observe the client's response. If the client shows signs of agitation or confusion or poses a threat, then the nurse should retreat and request assistance. The nurse shouldn't attempt to sit next to the client or examine the injuries without first announcing the nurse's presence and assessing the risk in the situation.

The school nurse learns that at least one of the children in the school has a new diagnosis of erythema infectiosum (human parvovirus) after developing a bright red facial rash. What interventions should be implemented to prevent a possible spread of the infection to other students in the school? Remove the pets from the classroom. Require the client to remain at home until the rash fades. Teach everyone to implement hand hygiene. Administer acetaminophen to the client.

4 Erythema infectiosum (human parvovirus) is transmitted through direct contact with respiratory secretions. The client is contagious for a week prior to the appearance of the rash, but not after the rash appears, so quarantine of the diagnosed client will not reduce transmission. However, other children may already have been infected and hand hygiene can reduce the spread of the infection. Human parvovirus is not transmitted by animals. Administering a pain reliever to the client will not reduce the risk of infection to others.

A parent tells the nurse that their 6-year-old child has severe nosebleeds. To manage the nosebleed, the nurse should tell the parent to: help the child assume a comfortable position with the head tilted backward. tilt the child's head backward and place firm pressure on the nose. help the child lie on the stomach and collect the blood on a clean towel. place the child in a sitting position with the neck bent forward and apply firm pressure on the nasal septum.

4 For the initial management of nosebleed, the client should sit up and lean forward with the head tipped downward. The soft tissues of the nose should be compressed against the septum with the fingers. The head-back position allows blood to flow down the throat, putting the client at risk for aspiration and allowing blood to enter the gastrointestinal tract, which can trigger vomiting.

A nurse gives a client the wrong medication. After assessing the client, the nurse completes an incident report. Which statement describes what will happen next? The facility will report the incident to the state board of nursing for disciplinary action. The incident will be documented in the nurse's personnel file. The nurse will be suspended and, possibly, terminated from employment at the facility. The incident report will provide a basis for promoting quality care and risk management.

4 Incident reports document unusual occurrences and deviations from care. Facilities use the internal documents to evaluate care, determine potential risks, or discover system problems that might have contributed to the error. This type of error won't result in a report to the state board of nursing or in the nurse's suspension. Some facilities do track the number of errors a nurse or a particular unit makes; the purpose of tracking errors is to provide appropriate education and to improve the nursing process.

The nurse assists the client to the operating room table and supervises the operating room technician preparing the sterile field. Which action, completed by the surgical technician, indicates to the nurse that a sterile field has been contaminated? Sterile objects are held above the waist of the technician. Sterile packages are opened with the first edge away from the technician. The outer inch of the sterile towel hangs over the side of the table. Wetness in the sterile cloth on top of the nonsterile table has been noted.

4 Moisture outside the sterile package contaminates the sterile field because fluid can be wicked into the sterile field. Bacteria tend to settle, so there is less contamination above waist level and away from the technician. The outer inch of the drape is considered contaminated but does not indicate that the sterile field itself has been contaminated.

A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, what should the nurse do first? Ask the parent about medication allergies. Inquire about the health of siblings at home. Obtain the child's vital signs. Institute droplet precautions.

4 The child with meningococcal meningitis requires droplet precautions for at least the first 24 hours after effective therapy is initiated to reduce the risk of transmission to others on the unit. After the child has been placed on droplet precautions, other actions, such as taking the child's vital signs, asking about medication allergies, and inquiring about the health of siblings at home, can be performed.

A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa, throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary importance? Talking with the client's family about his angry feelings Performing an assessment for tardive dyskinesia Learning to effectively express needs to staff and others Demonstrating control over aggressive behavior

4 The client must demonstrate control over his aggressive behavior so that he won't hurt himself or others or destroy property in the hospital setting. A discussion of angry feelings with the family can occur at a later time. Performing an assessment for tardive dyskinesia isn't a priority in the situation described. If the client were taking neuroleptic medication, a baseline assessment for tardive dyskinesia would already have been performed. The client's learning of effective communication and coping skills is a later goal, but not of primary importance.

One evening, the client takes the nurse aside and whispers, "Don't tell anybody, but I'm going to call in a bomb threat to this hospital tonight." Which action is the priority? warning the client that his telephone privileges will be taken away if he abuses them offering to disregard the client's plan if he does not go through with it notifying the proper authorities after saying nothing until the client has actually completed the call explaining to the client that this information will have to be shared immediately with the staff and the health care provider (HCP)

4 The priority is to explain to the client that this information has to be shared immediately with the staff and the HCP because of its serious nature. Safety of all is crucial regardless of whether the client follows through on his plan. It is possible that the client is asking to be stopped and that he is indirectly pleading for help in a dysfunctional manner. Bargaining with the client, such as warning him that his telephone privileges will be taken away if he abuses them, or offering to disregard his plan if he does not go through with it, is inappropriate. Saying nothing to anyone until the client has actually completed the call and then notifying the proper authorities represent serious negligence on the part of the nurse.

The nurse is planning care with an older adult who is at risk for falling because of postural hypotension. Which intervention will be most effective in preventing falls in this client? Complete a fall diary. Attach a sensor to the client that will alarm when client attempts to get up. Encourage a family member to stay with the client. Instruct the client to sit, obtain balance, dangle legs, and rise slowly.

4 There are many risk factors for falls in older adults. Postural hypotension is a common risk. The nurse should instruct the client about postural hypotension and provide practical information regarding how to sit on the bed or chair, dangle the legs first and then rise slowly, supported by a walker if necessary.A diary of instances of an individual's falls may predict future falls by tracking the events and behaviors at the time of the fall, but it is not the most effective in preventing the fall.Asking a family member to be present at all times is not necessary or realistic for this client whose fall risk is attributed to the potential for postural hypotension.Attaching a sensor to the client or bed is reserved for clients who are at a serious risk for injury.

The emergency department nurse is assessing a client with reports of right-sided dull, abdominal and flank pain, nausea, and vomiting. The client's temperature is 101.2° F (38.4° C), pain is 10 out of 10, and rebound tenderness is exhibited. The health care provider orders: VS q 30 min, CBC, morphine 2 mg IM q 4 hours, regular diet, and enemas until clear. Which orders should the nurse question? Select all that apply. morphine CBC vital signs regular diet enemas until clear

4-5 The nurse should question the enema order, as enema could cause the appendix to burst. If the condition is appendicitis, the client should be NPO for possible surgery so a regular diet should not be given to the client. It is important that the client does not take laxatives or enemas to relieve constipation as these medications could cause the appendix to burst.

On an oncology unit, the nurse hears noises coming from a client's room. The client is found throwing objects at the walls and has just picked up the phone and is screaming, "How can God do this to me? It's the third type of cancer I've had. I've gone through all the treatment for nothing." In what order of priority from first to last should the nurse make the interventions? All options must be used.

The first priority is a safe environment so the client and nurse are not hurt by the phone. Then, it is important to acknowledge the client's anger to help diffuse it. As the client calms down, the nurse can explore the client's feeling in more depth. Since the client implies anger at God, a clergy consult may be appropriate.