Practice NCLEX

The nurse is caring for a patient who sustained a femur fracture following a fall. Which common physical hazards can increase the risk of falling? Select all that apply. 1. Inadequate lighting 2. Barriers in the normal walking path 3. Sudden decrease in blood glucose levels 4. Lack of safety devices in homes 5. Sudden rise in blood pressure

1, 2, 4 Common physical hazards that increase the risk of falls are inadequate lighting, barriers in the normal walking path, and lack of safety devices in homes. Although a sudden decrease in blood glucose levels and a sudden increase in blood pressure may increase the risk of fall, these are not physical hazards.

The nurse cares for a patient with AIDS who has acquired jiroveci pneumonia. Which of the following precautions levels is appropriate for this patient? 1. Contact precautions. 2. Standard precautions. 3. Airborne precautions. 4. Droplet precautions.

2. Standard precautions. Jiroveci pneumonia is an opportunistic infection that only occurs in immunocompromised patients. Anyone with normal immune system function cannot "catch" this infection.

The medical/surgical nurse watches a student nurse prepare a sterile field. Which of the following actions, if performed by the student nurse, requires further instruction? 1. The student nurse drops the sterile gloves into the sterile field before disposing of the outer packaging. 2. The student nurses' hands, once in the sterile gloves, do not go above her head or below her waist. 3. The student nurses places the sterile drape, then turns to grab a packaged set of sterile gloves from the table behind her. 4. The student nurse places an unwrapped sterile 4x4 on the sterile drape.

3. The student nurse cannot turn her back on the sterile field or it is no longer considered sterile

The nurse in charge is evaluating the infection control procedures on the unit. Which finding indicates a break in technique and the need for education of staff? a. The nurse aide is not wearing gloves when feeding an elderly client. b. A client with active tuberculosis is asked to wear a mask when he leaves his room to go to another department for testing. c. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care. d. The nurse puts on a mask, a gown, and gloves before entering the room of a client on strict isolation.

Answer C. There is no need to wear gloves when feeding a client. However, universal precautions (treating all blood and body fluids as if they are infectious) should be observed in all situations. A client with active tuberculosis should be on respiratory precautions. Having the client wear a mask when leaving his private room is appropriate. Persons with exudative lesions or weeping dermatitis should not give direct client care or handle client-care equipment until the condition resolves. Strict isolation requires the use of mask, gown, and gloves.

The medical/surgical nurse cares for a middle-aged patient with a wound infected with MRSA (Methicillin-resistant Staphylococcus aureus). Which of the following protective safety items, if worn by the nurse, would be considered appropriate? A. Shoe covers, a gown, and gloves. B. A gown and gloves. C. Gloves only. D. A mask, gown, and gloves.

B. A gown and gloves. A patient infected with MRSA requires contact precautions.

A patient is ordered to undergo a CT scan with contrast dye. The most important action for the nurse to take in regard to patient safety is to: A. Confirm that the consent form is signed. B. Raise the side rails of the patient's bed. C. Check the patient's allergy list. D. Encourage fluids when the patient returns from the scan.

C. Although encouraging fluids is important to flush out the dye, checking for linked dye allergies is more important for safety. The dye has iodine, which is linked to shellfish allergy.

The nurse cares for a 4-year-old patient recovering from otoplasty surgery. The child is anxious and continually reaches toward his head. The nurse should choose which type of restraints? A. Vest restraint. B. Wrist restraints. C. Elbow splints. D. Mitt restraints.

C. Elbow splints are secured around the arms to prevent the child from reaching the surgical repair and disturbing it. Mitt restraints would still allow the child to reach the ears, as would a vest restraint. Wrist restraints prohibit movement at the shoulder as well and should be considered as a last resort

The nurse cares for a patient admitted with persistent bloody cough, night sweats, and multiple infiltrates and nodules identified on chest x-ray. Which type of infection precaution is best for this patient? **Bonus points if you can give the specific precautions after selecting answer** A. Droplet. B. Contact. C. Standard. D. Airborne.

D. Airborne. Night sweats, weight loss, bloody sputum, country of origin, and nodules on chest x-ray are symptoms of tuberculosis. An N95 mask/PAPR is necessary. Negative air pressure room, no student nurse/pregnant woman entry, pt does not leave room unless emergency and with reverse precautions.

The home health nurse is watching the caregiver change the sternotomy dressing on the postoperative client. Which action by the caregiver identifies correct principles of infection control? 1. The caregiver selects a previously opened gauze to cover the sternal wound. 2. The caregiver dons gloves before removal of the old dressing and then applies the new dressing. 3. The caregiver covers her mouth with her hand when she sneezes and then continues with the dressing change. 4. The caregiver washes hands before removal of the soiled dressing and again before applying the clean dressing.

The caregiver washes hands before removal of the soiled dressing and again before applying the clean dressing. The single most effective technique to prevent the spread of germs and bacteria is hand washing. The initial step with all aseptic procedures is hand washing. Using previously opened gauze, not washing hands after sneezing, and not applying new gloves after removing the old dressing increase the risk of wound contamination as a result of poor aseptic technique.

The preoperative nurse assists the nurse anesthetist with the insertion of a central venous catheter. The sterile absorbent pad and several pieces of gauze are saturated with blood. What is the best method of disposal for this material? a. Double bag the material in a yellow trash bag and tie it closed. b. Place the material inside of a clear sealable bag and place in the normal trash. c. Place the material in a red biohazard bag. d. Put the material in the sharps container.

c. OSHA defines biohazard waste as "Any liquid or semi-liquid blood or other potentially infectious materials." These items must be placed in a sealable red biohazard bag for appropriate disposal.

The nurse cares for an elderly patient with dementia who regularly gets out of bed and wanders, presenting a fall risk. Before the nurse raises all four side-rails of the bed, he must: a. Perform a thorough skin assessment. b. Make sure the call light and water is within reach of the patient. c. Obtain an order for restraints. d. Apply non-slip foot wear and discontinue the patient's IV.

c. Raising three of the four bed rails is not considered a restraint as it leaves an avenue for the patient to exit the bed. Once the fourth bed rail is raised, the nurse must obtain a restraint order because the patient is then confined to only the bed.