RN QBank Safe and Effective Care Environment (Management of Care and Safety and Infection Control)

The home care nurse visits a client diagnosed w/lupus erythematous. When instructing the client, it is MOST important for the nurse to include which? 1. "Ask your physician to order a lipid profile and a urinalysis w/the yearly examination" 2. "Ask your physician to include a BUN w/the examination" 3. "Seek psychological support w/a support group if you get depressed" 4. "Vigorous exercise will help w/the aching and stiffness in your joints"

1. "Ask your physician to order a lipid profile and a urinalysis w/the yearly examination" Proteinuria and hyperlipidemia are common w/SLE, instructing the client empowers him/her to assume responsibility for health

The school nurse concludes a high-school students' class about menstruation w/a discussion of TSS. Which of the following statements by a student to the nurse indicates further teaching is necessary? 1. "I only use super absorbent tampons when I am menstruating" 2. "I will avoid all kinds of vaginal products that contain deodorants" 3. "If I begin to vomit or have diarrhea during my period, I will contact my physician" 4. "I will use tampons during the day and sanitary pads at night"

1. "I only use super absorbent tampons when I am menstruating" Superabsorbent tampons increase vaginal dryness and can predispose the vaginal walls to damage

At 5 pm, the nurse notes that the last entry in a patient's chart was at 9 am. The nurse on the previous shift did did not complete the chart and did not sign the nurses' notes. Which of the following actions by the nurse is BEST? 1. Leave a note on the front of the chart asking the nurse to make a late entry and begin charting on the line below the last entry in the nurses' notes 2. Leave enough space for the previous nurse to complete charting when the nurse returns the next day 3. The evening nurse withholds all charting until the previous nurse returns to complete charting for care delivered 4. Contact the nurse from the previous shift and ask for a report so the evening nurse can complete the charting

1. Leave a note on the front of the chart asking the nurse to make a late entry and begin charting on the line below the last entry in the nurses' notes Charting should be timely and accurate; begin charting on the next line

A severe storm has blown out the windows on a 30-bed med/surg unit. The nurse determines that clients have to be evacuated to other rooms throughout the hospital. Which client should the nurse transfer FIRST? 1. A 40-year-old client admitted w/exacerbation of asthma who is receiving nebulizer treatments 2. A 56-year-old client w/unstable type 1 diabetes and a recent blood glucose of 124 mg/dL 3. A 58-year-old client transferred from cardiac intensive care earlier in the day post-MI 4. A 60-year-old client w/a peptic ulcer who is receiving a blood transfusion

1. A 40-year-old client admitted w/exacerbation of asthma who is receiving nebulizer treatments Client is at risk of ineffective airway clearance d/t particles in the air from storm debris and damage to the windows

The nurse at the preschool learns that a child has developed Hepatitis A. The nurse instructs the staff about S/S of Hepatitis A. The nurse informs the staff that which of the following is the MOST likely symptom of Hepatitis A in young children? 1. Anorexia 2. Jaundice 3. Arthralgia 4. Clay-colored stools

1. Anorexia Anorexia, malaise, lethargy and easy fatigability are most common symptoms

A home health nurse makes an initial visit to a client diagnosed as legally blind. Which of the following recommendations should the nurse make FIRST? 1. Call a plumber to set the hot-water tank's thermostat at 100 degrees 2. Use battery-operated appliances rather than electrical appliances 3. Remove most of the furniture from home 4. Purchase clothing that is easy for the client to don

1. Call a plumber to set the hot-water tank's thermostat at 100 degrees Reduces possibility of burns by hot water

The fire alarm sounds in the general hospital that houses a locked acute inpatient psychiatric unit on the eighth floor. The alarm code indicates that the fire is in the their-floor medical unit. Which of the following actions should the eighth-floor nurse take FIRST? 1. Ensure that all patients are out of their rooms and in the dayroom 2. Assign a staff member to each of the unit's locked doors 3. Explore w/patients their past experiences w/fire and their current concerns 4. Prepare for evacuation of the unit using the stairs

1. Ensure that all patients are out of their rooms and in the dayroom Priority is direct patient care (think RACE, even though fire is not on this unit); psychiatric patients are usually mobile versus confined to bed, and the unit usually has a central gathering area; staff should be assigned to check all rooms and direct patients to leave their rooms and go to the dayroom

The nurse in the PACU assesses the motor/sensory function of a client recovering from spinal anesthesia. The nurse notes that the client can feel the lower extremities and is able to wiggle the toes and move the legs. Which action should the nurse take NEXT? 1. Obtain the client's BP 2. Auscultate for bowel sounds 3. Assess the client's skin temperature and color 4. Auscultate breath sounds

1. Obtain the client's BP Ability to feel and move toes and legs indicates motor blockade from anesthetic is wearing off; blockage of autonomic nervous system may still be present and cause hypotension; monitor for hypotension, gradually elevate head of client's bed

During a sudden rise in a nearby river, the nurse at a day camp evacuates the children to an area away from the river. Which of the following actions should the nurse take NEXT? 1. Place an ID bracelet on each child 2. Go back for an adequate supply of water 3. Notify the parents of the children's location 4. Comfort children who are anxious

1. Place an ID bracelet on each child Aids in communication after rescue or recovery

The nurse is MOST likely to provide teaching regarding which to a 10-year-old boy and his parents? 1. Proper nutrition 2.Water safety 3. Suicide prevention 4. Sexual maturity

1. Proper nutrition Because of the threat of obesity and a diet-conscious society, children being to diet; teach importance of body-building nutrients and regular physical activities

The nurse is MOST likely to provide teaching regarding which to a 10-year-old child and his parents? 1. Sports safety 2. Water safety 3. Suicide prevention 4. Obesity prevention

1. Sports safety Bicycle and sports related injuries and proper nutrition are the two greatest concerns in school age children

The nurse cares for clients in the outpatient clinic. Which message should the nurse return first? 1. Parents report the umbilical cord of their 5 day old infant is dry and hard to the touch 2. Parents report the "soft spot" on the head of their 4 day old infant feels slightly elevated when the baby sleeps 3. Parents report the circumcision of their 3 day old infant is covered with yellowish exudate 4. Parents report that when their infant's crib was bumped, the 2 day old infant violently extended the extremities and returned to their previous position

2. Parents report the "soft spot" on the head of their 4 day old infant feels slightly elevated when the baby sleeps Fontanelle should feel soft and flat; fullness or bulging indicates increased intracranial pressure

The nurse manager of the psychiatric unit plans the biweekly unit-wide multidisciplinary team case conference focused on one particular client. Which client is MOST important for the manager to select for discussion? 1. A client who was admitted after a second serious suicide attempt and refuses to talk 2. A client toward whom the staff have a sharply conflicting attitudes and actions 3. A client who talks to invisible beings, takes possessions from other clients, and paces continually 4. A client, well known and well liked by the staff, whose diagnostic testing reveals a brain tumor

2. A client toward whom the staff have a sharply conflicting attitudes and actions Sharply conflicting attitudes and actions toward a client must be addressed, quickly and openly, and resolved; they are best prevented in the first place; often stem from a client with a personality disorder, particularly a borderline client, as part of the manipulative pattern of behavior

The nurse at a community health center is notified that a group of clients has been exposed to a hazardous chemical. Which of the following clients should the nurse see FIRST? 1. A client who says the chemical spilled onto his legs 2. A client who says he inhaled the chemical 3. A client who says she has HTN and type 2 diabetes 4. A client who says he swallowed the chemical

2. A client who says he inhaled the chemical Results in immediate absorption and can impair O2 exchange

While working at a local food processing plant, a flying object penetrates an employee's right eye. He is admitted to an ED. After administering pain medication, it is MOST important for the nurse to ask which of the following questions? 1. "Does the company provide worker's compensation?" 2. "Do you wear glasses?" 3. "Did you have visual problems before the surgery?" 4. "Are you afraid?"

2. "Do you wear glasses?" Helps determine whether material other than known object had penetrated the eye

A physician notifies the head of nursing of an inpatient medical unit that the chairperson of the board of the medical facility is going to be admitted for 24 hours. The physician relates to the head nurse that he considers one of the nurses on the unit disheveled and unkempt and asks that the nurse be reassigned for the duration of the chairpersons hospitalization. Which of the following responses by the nurse is MOST appropriate? 1. "I'll talk to the nurse about his appearance" 2. "I am unable to comply with your request" 3. "Where do you suggest this nurse work?" 4. "I have not had any complaints from any other clients"

2. "I am unable to comply with your request" Client care assignments are made based on knowledge and abilities of staff members; the head nurse is in the best position to assess the needs of the clients and make the appropriate assignments

The psychiatric inpatient unit has had four new admissions during the last shift. Which of the following patients should the nurse see FIRST? 1. A salesperson diagnosed w/postpartum depression after her baby was born w/Down's syndrome and her husband threatened to divorce her 2. A police officer w/PTSD history who was admitted w/agoraphobia after two of his co-officers were shot and killed in a drug raid 3. A computer programmer admitted w/a diagnosis of generalized anxiety disorder. The patient has extensive credit debt and his company just filed for bankruptcy 4. A college student admitted for depression and anxiety after his younger sibling committed suicide. His mother was recently diagnosed w/lung cancer

2. A police officer w/PTSD history who was admitted w/agoraphobia after two of his co-officers were shot and killed in a drug raid High potential for violence to self and/or others; male; easy access to weapons, and has knowledge of how to use them; needs assessment; orientation to the physical surroundings, staff, unit schedules and expectations, rules, and procedures for asking for help; any visitors would need to be particularly monitored for potential weapons, especially if they are other police officers and accustomed to carrying their guns

The nurse observes an NAP providing care on the med/surg unit. The nurse should intervene if which of teh following is observed? 1. The NAP performs perineal care for a client diagnosed w/a CVA 2. The NAP removes dead leaves form a plant in the client's room 3. The NAP removes the contact lenses from a client w/right-sided weakness 4. The NAP collects a clean catch urine specimen from a client diagnosed w/pneumonia

2. The NAP removes dead leaves form a plant in the client's room Caregivers should not be caring for plants and clients; plants should be cared for by a different person

The nurse on the med/surg unit notes a graduate nurse often seems rushed during the shift and is staying overtime w/out pay to complete work. The graduate nurse approaches the nurse and says, "I am having difficulty w/time management." Which initial response by the nurse is BEST? 1. "I have some ideas to help you better manage your time" 2. "How much practice did you get in school taking care of groups of patients?" 3. "What ideas do you have as to the reason for your time management difficulties?" 4. "Tell me how you feel about time in general"

3. "What ideas do you have as to the reason for your time management difficulties?" Best to initially assess graduate's perception of difficulty before offering solutions; conveys respect, allows for free expression and analysis of problem

A nurse returns to work in an inpatient environment after not practicing for 5 years. The returning nurse reports to the employee health nurse that she established hepatitis B immunity w/a previous employer. Which of the following responses by the employee health nurse is MOST appropriate? 1. "You must repeat the hepatitis immunity screen" 2. "Would you like to verify your immunity to hepatitis B w/a blood test?" 3. "Do you have a copy of the results of your hepatitis screening?" 4. "Did you receive the hepatitis vaccine in the deltoid?"

3. "Do you have a copy of the results of your hepatitis screening?" Confirms immunity

The nurse makes a patient assignment on the med/surg unit. The nurse assigns an LPN/LVN to a patient diagnosed w/localized herpes zoster. The LPN/LVN mentions to the nurse that she has never had the chickenpox. Which of the following statements by the nurse is MOST appropriate? 1. "Use standard precautions when caring for the patient" 2. "You will be fine, b/c the patient is on airborne precautions" 3. "I will assign the patient to another nurse" 4. " Are you concerned about caring for the patient?"

3. "I will assign the patient to another nurse" Should assign patient to an immune caregiver

The nurse observes the NAP perform mouth care on the client admitted with fever of unknown origin. Which action, if performed by the NAP, requires an intervention by the nurse? 1. The NAP applies petroleum jelly to the client's lips 2. The NAP cleanses the client's mouth w/agency approved rinse 3. The NAP rinses the client's mouth with a 50:50 solution of hydrogen peroxide and water 4. The NAP uses a soft bristled toothbrush to clean the client's teeth

3. The NAP rinses the client's mouth with a 50:50 solution of hydrogen peroxide and water Causes irritation of tissues and respiratory tract and may alter the normal flora of the mouth

The nurse supervises care provided to a client being treated with a radioactive implant for vaginal cancer. Which of the following situations, if observed by the nurse, requires an intervention? 1. The NAP spends a half an hour in the client's room helping w/morning cares 2. The NAP places all the equipment needed for morning care on the bedside table 3. The NAP stands behind the portable bedside shield placed at the foot of the client's bed 4. The NAP stands six feet away from the patient when talking to her

3. The NAP stands behind the portable bedside shield placed at the foot of the client's bed Shield should be placed on hallway side of client's bed to protect caregivers and visitors; do not stand at foot of bed

The triage nurse at an urgent care center prioritizes for evaluation. The nurse determines that which client should be seen FIRST? 1. The client receiving dialysis who missed the dialysis appointment the day before and reports swelling in the feet and ankles 2. The toddler who has a forehead laceration from a fall down five steps and who is currently smiling and playful 3. The client w/a history of chronic alcohol use who reports tremors, confusion, and feeling like the heart is racing 4. The woman at 8 weeks' gestation who reports vaginal spotting that has occurred off and on for the past several days

3. The client w/a history of chronic alcohol use who reports tremors, confusion, and feeling like the heart is racing Chronic alcohol use is the most common cause of hypomagnesemia, which may result in cardiac arrest; manifestations include increased neuromuscular irritability, tremors, tetany, seizures

The nurse cares for the client diagnosed with active TB. It is MOST important for the nurse to take which action? 1. Restrict visitors to immediate family only 2. Wear a gown and gloves at all times 3. Wear a mask and gloves when in direct contact w/the client 4. Dispose of waste articles more frequently

3. Wear a mask and gloves when in direct contact w/the client Airborne precautions required

The nurse observes that a HCP has ordered 100 mL D5W w/KCL 80 mEq to infuse in 0.5 hours. Which action should the nurse take FIRST? 1. Assess the client's UOP 2. Ensure the patency of the client's IV 3. Request an order for IV lidocaine 4. Contact the HCP

4. Contact the HCP Rate of IV administration should be no faster than 20 mEq/hr; contact HCP to clarify order

The middle of the evening shift on the inpatient psychiatric unit is unusually hectic; with a large census, high acuity level, three admissions in two hours, and a fourth admission on the way. The unit secretary goes down to the ED to get some needed paperwork for one patient. When she gets back to the unit, she angrily and repeatedly exclaims about the ongoing rudeness of the ED staff, including their not providing the necessary documents. She states, "I am going home!" and starts to go to the coatroom. What is the BEST response by the charge nurse? 1. "Take a deep breath. Give it some thought and let me know what you decide" 2. "You must stay here and do your job. If you leave, that will beinsubordination" 3. "Calm down. Overreacting does not do you or anyone else any good" 4. " We are not the ones who were rude to you. Do not leave us, because we need you"

4. " We are not the ones who were rude to you. Do not leave us, because we need you" Priority is getting through the immediate situation on the unit; points out reality; conveys genuineness, empathy, and positive regard, factors that help people to grow; accepts secretary's judgement and does not set up conflict by disagreeing or challenging by choice of words

The nurse on a bone marrow transplant unit receives a call from a coworker who reports that 2 days ago her husband was possibly exposed to TB at his job. Which of the following responses by the nurse is BEST? 1. "When did you have your last TB test?" 2. "What were the results of your last TB test?" 3. "Has your husband every been exposed to TB before?" 4. "Are you concerned that you may be infected with TB?"

4. "Are you concerned that you may be infected with TB?" Directly addresses the coworker's concerns; uses reflection

The nurse cares for clients on the surgical floor and has just received report from the previous shift. Which client should the nurse see FIRST? 1. A 35-year-old admitted three hours ago w/a gunshot wound ; 1/5 cm area of dark drainage noted on the dressing 2. a 43-year-old who had a mastectomy two days age; 23 mL of serosanguinous fluid noted in the JP drain 3. a 59-year-old with a collapsed lung d/t an accident; no drainage noted from chest tube in last eight hours 4. A 62-year-old who had an abdominal perineal resection three days ago; client reports chills

4. A 62-year-old who had an abdominal perineal resection three days ago; client reports chills Risk for peritonitis, should be assessed for further symptoms of infection

The nurse on the med/surg floor receives four new admissions. Which of the following clients should be placed in a private room? 1. A client diagnosed w/infectious mono 2. A client diagnosed w/Legionnaires' disease 3. A client diagnosed w/pneumococcal meningitis 4. A client diagnosed w/disseminated herpes zoster

4. A client diagnosed w/disseminated herpes zoster Requires airborne and contact precautions

When administering preoperative medication to a client, the nurse notices a large number of small insects crawling out of the closet where the client placed his suitcase. The client refuses to allow the nurse to inspect his luggage. Which of the following actions by the nurse is MOST appropriate? 1. Notify security 2. Kill the insects 3. Inspect the client's bag 4. Double-bag the suitcase and insects

4. Double-bag the suitcase and insects Take action to limit the area of contamination

The charge nurse implements a change in the NAPs job description. The change increases the NAPs responsibilities and independence. A nurse w/15 years of service on the unit verbally agrees to the change, but her behaviors indicate that she does not agree w/the new job description. Which of the following actions by the charge nurse is MOST appropriate? 1. Inform the nurse that there is a conflict between her verbal statements and behavior 2. Schedule an appointment with the nurse 3. Ask the NAPs to accommodate the nurse 4. Facilitate an open discussion during a pre-scheduled meeting

4. Facilitate an open discussion during a pre-scheduled meeting Indirect approach; nurse not confronted directly about behaviors; peer pressure can be effective in dealing with situation

The nurse administers a tube feeding to a patient w/a baseline decreased mental status. Immediately after completing the tube feeding, it is MOST important for the nurse to place the client in which of the following positions? 1. Supine w/the HOB elevated 45 degrees 2. Supine w/the lower extremities elevated on pillows 3. High Fowler's or semi-Fowler's position 4. On the right side w/the HOB elevated

4. On the right side w/the HOB elevated Promotes emptying of stomach while preventing aspiration

The nurse makes rounds on the medical unit to assess the care given by the NAP. Which of the following observations requires an intervention by the nurse? 1. The NAP places the fingers of one hand on the wrist of a patient in order to evaluate the respirations 2. The NAP prepares to take a BP in the left arm of a patient recovering from a right mastectomy 3. The NAP weighs a patient on a standing scale while the patient is balanced on crutches 4. The NAP prepares to take an oral temp on a patient recovering from a rhinoplasty

4. The NAP prepares to take an oral temp on a patient recovering from a rhinoplasty Rhinoplasty compromises ability of patient to breathe through the nose d/t the packing in both nostrils

The charge nurse of a psychogeriatric unit makes rounds on the unit. Which of the following situations requires and IMMEDIATE intervention by the nurse? 1. The dietary aide removes a full breakfast tray untouched by a patient w/major depression who is still in bed wearing night clothing 2. The psychiatric aide makes the bed while a patient w/schizophrenia is sitting in the bedside chair shaving w/a disposable razor and mirror 3. The LPN/LVN assigned to medication administration argues loudly w/a bipolar patient who is refusing to take prescribed medication 4. The PCT places personal care items in reach of a patient w/stage 2 dementia of Alzehimer type and then leaves to fill the wash basin w/water

4. The PCT places personal care items in reach of a patient w/stage 2 dementia of Alzehimer type and then leaves to fill the wash basin w/water Patient is at risk for choking on inedible items such as soap, lotions, caps of sample bottles, etc.

The nurse returns to a senior citizen center to evaluate the effectiveness of a presentation about how to prevent falls among seniors. The nurse determines that teaching was effective if the seniors state which of the following? SELECT ALL THAT APPLY 1. "I started taking Tai Chi classes" 2. "I have a new pair of athletic shoes w/deep treads" 3. "I went to the eye doctor to have my vision checked" 4. "My physician reviewed all of my medications" 5. "I stopped exercising so I won't fall" 6. "I bought some new lamps for my home"

1. "I started taking Tai Chi classes" 3. "I went to the eye doctor to have my vision checked" 4. "My physician reviewed all of my medications" 6. "I bought some new lamps for my home" -Exercise is one of the most important ways to decrease the chance of falling; Tai Chi improves balance and coordination - Ensures that glasses are correct and will rule out glaucoma and cataracts, which limit vision - Medications can cause client to be drowsy or light-headed, which can contribute to falls - Older clients need brighter lights to see well

The nurse makes a prenatal visit to the home of a woman who is pregnant with her first child. It is MOST important for the nurse to intervene if which observation is made? 1. A cat is sleeping peacefully on the windowsill 2. Cleaning supplies are in an unlocked cabinet under the kitchen sink 3. There are throw rugs on the living room floors 4. The smoke detector is chirping intermittently

1. A cat is sleeping peacefully on the windowsill Cat presents a toxoplasmosis risk to the pregnant woman and her unborn/newborn infant; toxoplasmosis is a parasitic disease transmitted in the feces of cats who have eaten infected mice and animals; preventative measures include hand washing after touching cats, have the liter box changed daily (it takes about 1-5 days for the cat's feces to become infectious) by someone other than the pregnant woman, prevent cats from eating raw meat or wild animals, wear gloves while gardening, do not garden in areas frequented by cats, avoid under cooked meat and contact with stray animals

Four mothers have delivered their infants vaginally within a 10-minute period. Which mother should the nurse evaluate FIRST? 1. A multipara who delivered a 5 lb 8 oz baby girl after 2.5 hours of labor and has a history of rapid labor 2. A primipara who delivered a 7 lb 2 oz baby boy after 16 hours of labor and is crying 3. A multipara who delivered a 6 lb 3 oz baby boy after 12 hours of labor and has a recent history of alcohol and marijuana use 4. A primipara who delivered a 7 lb 10 oz baby girl after 19 hours of labor and has a history of having been abused as a child

1. A multipara who delivered a 5 lb 8 oz baby girl after 2.5 hours of labor and has a history of rapid labor Precipitous labor is a risk factor for early postpartum hemorrhage and also for amniotic fluid embolism; it is defined as a labor pattern which progresses quickly and ends less than 3 hours from when it begun; mulitpara status, small fetus in a favorable position, and history of previous rapid labors are contributing factors to this rapid labor.

The triage nurse for the women's health center receives 4 phone messages. The nurse should direct which client to come to the health care facility IMMEDIATELY? 1. A multipara woman at four weeks gestation reporting unilateral, dull abdominal pain 2. A primigravida woman at five weeks gestation having vaginal spotting and some cramping 3. A multigravida woman at six weeks gestation reporting frank, red vaginal bleeding w/moderate cramps 4. A primipara woman at seven weeks gestation reporting an increase in whitish vaginal secretions

1. A multipara woman at four weeks gestation reporting unilateral, dull abdominal pain Needs to be evaluated for ectopic pregnancy

An adolescent girl comes to the outpatient clinic when she discovers that the person she had intercourse with 3 weeks ago has syphilis. Which of the following does the nurse expect to see if the client has contracted syphilis? 1. A papule-like lesion in the vaginal area 2. Abnormal pap smear 3. Non-reactive blood serology test 4. Cluster of painful blisters on the genital area

1. A papule-like lesion in the vaginal area Primary syphillis; chancre develops within 2-6 weeks; appears at point of entry; starts as small papule, develops into painless ulcer

The triage nurse at a busy urgent care center prioritizes clients for evaluation. The nurse determines that which of the following clients should be seen FIRST? 1. A woman at 6 weeks gestation who complains of left lower quadrant abdominal pain and vaginal spotting 2. A toddler whose parents report N/V for 2 hours and a fever of 102.8 F 3. A patient diagnosed w/renal disease who missed his dialysis appointment the day before and who complains of swelling in his feet and ankles 4. A toddler who has a forehead laceration from a fall and who is smiling and playful

1. A woman at 6 weeks gestation who complains of left lower quadrant abdominal pain and vaginal spotting Symptoms of ectopic pregnancy, which may r/i death if allowed to progress

The nurse cares for a 2-year-old who accidentally ingested some of the parent's medication 3 hours ago. It is MOST important for the nurse to question which of the following? 1. Administer activated charcoal orally 2. Give the child a small dish of ice cream 3. Position the child in a semi-Fowler's position 4. Observe for N/V

1. Administer activated charcoal orally Activated charcoal should be administered w/in one hour of ingestion of toxin; stem states that poison ingested 3 hours ago

The industrial nurse is called to see a worker who was exposed to an extensive level of radiation. The worker appears anxious and reports lower right intermittent abdominal pain. Which of the following actions should the nurse take FIRST? 1. Assess the abdominal pain 2. Encourage the client to relax 3. Obtain an order for pain medication 4. Begin the decontamination process

1. Assess the abdominal pain Clients contaminated with radiation do not pose a health risk to medical personnel; nurse must assess workers complaint before implementing

An elementary school teacher noticed a student's eyes have been severely inflamed for 10 days. The student stated her parents refused to take her to a physician. The teacher notifies the school nurse. Which of the following actions should the nurse take FIRST? 1. Discuss the condition of the child's eyes w/the parents 2. Notify the principal of the parents' refusal to seek health care 3. Notify the child protective division of the department of human resources 4. Cleanse the drainage from the child's eyes

1. Discuss the condition of the child's eyes w/the parents Data collection needs to be objective, not based on the child's report

The charge nurse meets with the head nurse to discuss the staff's concerns about implementing a new delivery of care model. The charge nurse gives the head nurse a document providing extensive rationales about why the staff has voted not to implement the new model. Which of the following actions by the head nurse is MOST appropriate? 1. Inform the charge nurse that the process was inappropriately initiated 2. Reprimand the charge nurse in writing for insubordination 3. Instruct nurse to inform the staff that the delivery model will be implemented 4. Meet with the staff to obtain feedback regarding their concerns about the delivery model

1. Inform the charge nurse that the process was inappropriately initiated The role of the charge nurse is to support agency decisions; charge nurse should have informed staff that voting would not negate the process

The nurse on the surgical unit administers an incorrect dose of medication to the client. The nurse should take which of the following actions? SELECT ALL THAT APPLY 1. Record the dose of the medication administered 2. Photocopy the incident report for the nurse's personal file 3. Perform and assessment of the client 4. Contact the physician 5. Chart any adverse reaction the client experienced 6. Submit the report to the risk manager within 48 hours

1. Record the dose of the medication administered 3. Perform and assessment of the client 4. Contact the physician 5. Chart any adverse reaction the client experienced - Record the dose of medication administered and dose of medication ordered - Assess and factually record client's response - Record any action taken by the physician - Record factually; also record staff's response to adverse reaction

Six months ago a NAP was injured in a MVA. Her right leg was badly damaged and after rehab the NAP walks with an extreme limp and slow, unstable gait. The NAP prepares to return to work on an acute care surgical unit. When planning for the return of the NAP, the nurse should take which of the following actions? 1. Survey other units for positions that are more suitable for the NAP 2. Recommend the NAP take a leave of absence w/out pay until the NAP receives disability benefits 3. Transfer the NAP to a shift during which the work on the surgical unit is less demanding 4. Transfer a major portion of the NAPs duties to the other NAPs

1. Survey other units for positions that are more suitable for the NAP ADA recommends that the NAP be offered a position that is appropriate

The home care nurse returns to the office to find four phone messages. Which of the following messages should the nurse return FIRST? 1. The daughter of a client diagnosed with lung cancer states that her father refuses chemotherapy today 2. A client is asking when staples can be removed from his abdominal incision 3. A client w/a colostomy complains that the skin is raw around the stoma 4. The wife of a client w/a CVA states that her husband is refusing a bath

1. The daughter of a client diagnosed with lung cancer states that her father refuses chemotherapy today Assess whether client is experiencing side effects

The HCP prescribes ampicillin IM for an elderly client. The injection site selected by the nurse should depend on which finding? 1. The size of the muscle mass 2. The total number of injections ordered 3. The position of the client in bed 4. The gauge of the needle

1. The size of the muscle mass Must be injected deeply into large muscle mass; injection too close to nerve or blood vessel causes neurovascular damage; best site for adult ventrogluteal, best site for children vastus lateralis

A 45-year-old patient with a 10-year history of rheumatoid arthritis is being prepared for discharge from the hospital. Which of the following instructions is essential for the nurse to include? 1. "If it hurts to perform an activity, don't do it" 2. "Move your joints as much as you can each day" 3. "Eat a diet high in complex carbohydrates and calcium" 4. "Return to work on Monday"

2. "Move your joints as much as you can each day" Maintaining mobility is a physical need; most important; achieved by exercises and independent ADLs; take warm shower or tub bath to increase blood flow, decrease pain and increase joint mobility; walking and swimming are good exercises

The nurse on the med/surg unit prepares several clients for discharge today. Which of the following statements, if said by one of the clients to the nurse, indicates the need for further teaching? 1. "Because my colostomy is pink and moist. I can take a relaxing bath" 2. "Now that I've had this old hip replaced. I can get back on the tennis court? 3. "In about a week, I'll need to have the stitches removed from my head. Perhaps I should wear a hat while I'm outdoors" 4. "I can't wait to go for a walk in the park. My knee feels better w/the new joint in place"

2. "Now that I've had this old hip replaced. I can get back on the tennis court? Playing tennis would put the patient at risk for dislocation of the new hip prosthesis

The nurse in the outpatient clinic receives a call from the parent of a teenager diagnosed with infectious mono. The mother complains that her child seems angry and depressed since developing mono. Which of the following responses by the nurse is MOST appropriate? 1. "Why do you think your child is angry?'" 2. "Teens become frustrated b/c of feeling weak and fatigued" 3. "Would you like the physician to talk with your child?" 4. "My child had mono and was crabby all the time"

2. "Teens become frustrated b/c of feeling weak and fatigued" Because of teen's active lifestyle, may react with anger and depression to the weakness and fatigue; allow teen to vent and reassure teen that activities can be resumed after the acute phase

The nurse in the diabetic specialty unit has just received report. Which of the following clients should the nurse see FIRST? 1. A 17-year-old boy with irritability complaining of a fatigue 2. A 28-year-old woman with fruity breath smell complaining of thirst 3. A 38-year-old man w/a BP of 120/50 complaining of frequent urination and thirst 4. A 45-year-old woman w/a BP of 90/60 and skin is hot and dry to touch

2. A 28-year-old woman with fruity breath smell complaining of thirst Indicates metabolic acidosis from ketosis; increased risk of injury to client

The nurse cares for clients on the med/surg floor. Because of a staffing shortage, an RN has been reassigned from postpartum. Which of the following clients should the nurse give to the reassigned nurse? 1. A client receiving t-Pa 2. A client diagnosed w/Raynaud disease who has a sympathectomy 3. A client admitted in sickling crisis 4. A client diagnosed w/dysrhythmia who had a permanent pacemaker implanted

2. A client diagnosed w/Raynaud disease who has a sympathectomy Raynaud disease is a form of intermittent arteriolar vasoconstriction; sympathectomy interrupts the sympathetic nerves; stable client w/ an expected outcome

The nurse in the outpatient clinic administers a Mantoux test to a client. The client's history indicates that being HIV positive and has been treated during the past years for Candida albicans and cytomegalovirus. The nurse should expect which reaction to the test? 1. A false-positive reaction to the test 2. A false-negative reaction to the test 3. A systemic reaction to the testing material 4. Increased SE associated w/the test

2. A false-negative reaction to the test Negative skin test doesn't rule out TB infection in persons who are immunosuppressed since they are unable to initiate and adequate response to the skin tests

The nurse asks the NAP to perform soapsuds enemas for a patient scheduled for a diagnostic test.The nurse should: 1. Observe the returns from the enemas in the patient's bedside commode 2. Ask the NAP to describe the returns from the enema 3. Ask the patient to describe the returns from the enemas 4. Palpate the patient's abdomen, noting firmness and tenderness

2. Ask the NAP to describe the returns from the enema Describing returns from the enema is a part of the responsibilities delegated; nurse should monitor performances and results according to established goals

The nurse in the ED assesses an elderly client. The client's daughter states that her mother has glaucoma, is extremely hard of hearing, and has been experiencing abdominal pain for the past 24 hours. Which of the following actions by the nurse is the MOST appropriate? 1. Using a numeric rating scale, determine the intensity of the client's pain 2. Ask the client if she wears hearing aids 3. Administer pain medication 4. Ascertain when the client last saw a physician

2. Ask the client if she wears hearing aids Tools used for rating pain are ineffective if client can't hear what is being asked or if the client can't see the pain rating scale

Which of the following is an appropriate and cost-effective measure for the charge nurse to implement during a low-census shift? 1. Keep all staff in case the census increases 2. Contact the hospital supervisor 3. Dismiss excessive staff w/instructions to stay by the phone 4. Dismiss excessive staff and given them the day off w/out pay

2. Contact the hospital supervisor Excessive staff may be floated to another unit that requires additional personnel; only supervisor will have this information

The nurse receives a phone call from a neighbor's teenaged son telling the nurse that his dad (age 47 years) has been experiencing severe midsternal chest pain for 15 minutes. The teen cannot get his father to seek medical assistance. Which of the following activities should the nurse perform FIRST? 1. Go to the neighbor's home w/a stethoscope and BP cuff 2. Contact the neighbor and tell him that his son asked the nurse to see his father 3. Contact 911 4. Ask the neighbor's son if there are color changes and dyspnea

2. Contact the neighbor and tell him that his son asked the nurse to see his father Need to make sure client wants assistance and will give nurse permission to enter the home

The nurse cares for a patient diagnosed w/COPD who is brought to the hospital by EMS for increasing SOB. The patient is placed on a cardiac monitor and an IV access is established. The patient's VS are BP 130/70, HR 84, RR 26 and O2 sats are 100% on 6L NC. Which of the following interventions should the nurse perform FIRST? 1. Attempt to wean the patient's supplemental O2 2. Elevate the HOB to 45 degrees 3. Administer theophylline (Theo-Dur) 4. Obtain ABGs as ordered

2. Elevate the HOB to 45 degrees Proper positioning maximizes respiration and decreases respiratory effort

The nurse in a 50-bed nursing facility discovers a fire in the soiled utility room. Arrange the following actions by the nurse in the appropriate order from MOST important to LEAST. All options must be used. 1. Locate all the residents 2. Move clients away from the fire 3. Pull the fire alarm 4. Close all the fireproof doors

2. Move clients away from the fire 3. Pull the fire alarm 4. Close all the fireproof doors 1. Locate all the residents - Remember the acronym RACE (rescue/remove, alarm, confine/close, evacuate) - Do this once first step is done - Prevents fire from spreading - Appropriate if evacuation required

The client is brought to the ED by EMS w/a blood glucose level of 32 mg/dL. The client received 1 ampule of 1 mg of glucagon IM 10 minutes prior to arrival. While assessing the client, the nurse should instruct the NAP to perform which action? 1. Recheck the client's blood glucose in 30 minutes 2. Obtain 1/2 cup of OJ 3. Give the client a high protein nutritional beverage 4. Obtain an EKG on the client

2. Obtain 1/2 cup of OJ If the client is able to take oral fluids, a high carbohydrate beverage should be given

The client is brought to the ED by ambulance w/a BG level of 32 mg/dL. The client is drowsy w/cold, clammy skin. The client received 25 mL of 50% dextrose in water before arrival. Which action is a priority for the nurse to take? 1. Recheck the clients BG 2. Obtain OJ for the client 3. Administer 1 mg of glucagon IM 4. Obtain an ECG on the client

2. Obtain OJ for the client Rapidly absorbed carbohydrates indicated for moderate hypoglycemia

The nurse supervises an LPN/LVN provide care to a patient w/an infected abdominal wound. The nurse notes a Penrose drain in place and the wound is draining copious amounts of purulent drainage. The nurse determines care is appropriate if which of the following is observed? 1. The LPN/LVN dons clean gloves, removes the soiled dressing, and puts on a pair of clean gloves to dress the wound 2. The LPN/LVN dons clean gloves, removes the soiled dressing, changes to sterile gloves, and uses sterile dressings to cover the wound 3. The LPN/LVN dons sterile gloves, removes the soiled dressing, changes to clean gloves, and uses sterile dressings to cover the wound 4. The LPN/LVN places the client in protective isolation, removes the old dressings using sterile gloves, and applies sterile dressing using sterile technique

2. The LPN/LVN dons clean gloves, removes the soiled dressing, changes to sterile gloves, and uses sterile dressings to cover the wound Remove dressing w/clean gloves, remove gloves and wash hands, don sterile gloves to perform sterile dressing change

The nurse supervises care on the med/surg unit. Which situation should the nurse attend to FIRST? 1. An NAP enters the room of the client diagnosed with Pneumocystis cariniipneumonia wearing a gown, mask, and gloves 2. The client who has just returned to the unit after right pneumonectomy is placed in a room w/the client diagnosed with COPD 3. The family of the client reports that the toilet is overflowing in the client's bathroom 4. The client diagnosed w/TB is ready for discharge and waiting for discharge instructions

2. The client who has just returned to the unit after right pneumonectomy is placed in a room w/the client diagnosed with COPD Post-op clients are considered "clean" and should not be placed w/a client that is considered "dirty"

The nurse cares for the client diagnosed w/an acute episode of pancreatitis. The nurse should intervene if which finding is observed? 1. An NAP obtains and records the daily weight 2. The spouse assists the client to the bathroom 3. The LPN/LVN maintains NG suctioning 4. A nurse administers fentanyl IV

2. The spouse assists the client to the bathroom Bed rest is needed to decrease the metabolic rate and the secretion of pancreatic enzymes; bathroom privileges are not allowed

As part of a health center educational program on TB, skin tests are offered as a screening measure. Which statement by a participant to the nurse requires further exploration by the nurse? 1. "My grandfather had TB and died from it" 2. "When I have these skin tests, nothing ever shows up" 3. "I had a shot for TB 5 years ago" 4. "I won't take medicine even if they do find something"

3. "I had a shot for TB 5 years ago" Most indicative of possible contraindication for skin testing; need to explore meaning of work "shot" and what was actually done; may have been the bacillus Calmette-Gueerin (BCG) vaccine used to promote active immunity to TB; false-positive reactions to TB skin testing can occur in individuals who have received this vaccine

A client is scheduled for abdominal surgery. During surgery, the client's significant other requests information regarding the client's status. Which of the following responses by the nurse is BEST? 1. "The physician will be out to talk w/you after the surgery is complete" 2. "I am sorry. I can only give out information to family members" 3. "Let me go back and get an update. I will be right back" 4. "I'm sure she is doing fine, so just sit back and relax"

3. "Let me go back and get an update. I will be right back" Important to respect client's personal lifestyle choice; nurse acts as the client's advocate when providing partner w/accurate information

The 22-year-old female client tells the nurse in the family planning clinic that the client is fearful of contracting a sexually transmitted infection. Which statement, if made by the nurse, is BEST? 1. "Douche w/a vinegar solution after each act of intercourse" 2. "Insert a diaphragm w/spermicide before every act of intercourse" 3. "Use a condom and spermicide w/every act of intercourse" 4. "Limit your sexual encounters to people that you know"

3. "Use a condom and spermicide w/every act of intercourse" Condom avoids the deposit of semen, spermicide destroys some organisms

The home care nurse visits a client diagnosed w/AIDS. The nurse instructs the client's caregiver about how to prevent infection. What is MOST important instruction the nurse should give to the client's caregiver? 1. "Cover your nose and mouth when you sneeze or cough" 2. "Get rid of all pets in the home" 3. "Wash your hands frequently" 4. "Wash the client's dishes separately"

3. "Wash your hands frequently" Single best way to kill germs; caretaker should wash hands after going to the bathroom and before and after fixing food; should also wash hands before and after caring for the client

The nurse on the med/surg unit has just received report. Which client should the nurse see FIRST? 1. A 29-year-old woman undergoing peritoneal dialysis. The outflow appears bloody 2. A 35-year-old man diagnosed w/acute postinfectious glomerulonephritis. The client's blood pressure is 150-90 3. A 45-year-old woman diagnosed with P. jiroeci pneumonia. The client complains of a persistent dry cough 4. A 56-year-old man diagnosed w/angina. The client is scheduled for discharge today

3. A 45-year-old woman diagnosed with P. jiroeci pneumonia. The client complains of a persistent dry cough Opportunistic infection associated w/AIDS; causes progressive hypoxemia and cyanosis

The nurse is making client assignments on a med/surg unit. The staff includes one RN, an LPN/LVN, and an NAP. Which of the following clients should be assigned to the LPN/LVN? 1. A client who had a detached retina surgically repaired 4 hours ago 2. A client who requires assistance after receiving bowel prep for abdominal surgery 3. A client 1 day post-op after an appendectomy 4. A client 2 days post-op after a laminectomy w/spinal fusion

3. A client 1 day post-op after an appendectomy Stable client w/expected outcome

The nursing team at the home care agency consists of an RN, an LPN, and a NAP. The RN should assign to the LPN/LVN to which of the following clients? 1. A client just discharged from the hospital w/a diagnosis of HTN and hypothyroidism 2. A client recovering from a kidney transplant complaining of fever and tenderness over the transplant site 3. A client diagnosed w/regional enteritis requiring a dressing change for an abdominal dressing 4. A client recovering from a hip fracture requiring assistance w/a bath and hair washing

3. A client diagnosed w/regional enteritis requiring a dressing change for an abdominal dressing LPN/LVN recognizes normal from abnormal and can perform dressing change

The nurse on the med/surg unit has just received report. Which of the following clients should the nurse see FIRST? 1. A client 1 day post-op after an appendectomy 2. A client who had a detached retina surgically repaired 4 hours ago 3. A client w/an esophagogastric tube inserted 4. A client 2 days post-op after a laminectomy w/spinal fusion

3. A client w/an esophagogastric tube inserted Used to treat bleeding esophageal varices; VS for decreased BP and elevated P; ensure that balloon pressure and volume is maintained

The nurse receives report on the following patients upon arrival at the medicine unit. Which of the following patients should the nurse see FIRST? 1. A patient drinking contrast for an abdominal CT scan who complains of nausea 2. A patient w/a respiratory rate of 24 and an O2 sat of 94% on RA 3. A patient complaining of frequent small amounts of water diarrhea w/abdominal pain and nausea 4. A patient whose family member is threatening to sue the hospital and the nurse if the nurse doesn't talk w/the family immediately

3. A patient complaining of frequent small amounts of water diarrhea w/abdominal pain and nausea May indicate a possible bowel obstruction that can be life-threatening if the bowel perforates

The nurse admits a 6-month old with a diagnosis of RSV. The nurse should place the child in which of the following rooms? 1. A semiprivate room w/an infant diagnosed w/influenza 2. A semiprivate room w/an infant diagnosed w/Kawasaki syndrome 3. A private room w/sleeping accommodations 4. A private room w/out sleeping accommodations

3. A private room w/sleeping accommodations RSV causes bronchiolitis and requires contact precautions; parents are best providers of care for their children, sleeping accommodations are appropriate

The nurse prepares to discharge a client diagnosed w/AIDS. The client is going to the parents' home so that they can take care of the client. Which action should the nurse take INITIALLY? 1. Refer the client for home care 2. Assess if the client and the parents understand the dosing schedule and SE of the medications 3. Ask the client about what kind of help is needed from the parents 4. Encourage the parents to join a support group

3. Ask the client about what kind of help is needed from the parents Should first determine the client's needs and then assess whether parents are able to meet client's needs; after assessment is complete, then begin implementation

The nurse on the med/surg unit administers digoxin mg by direct IV. During the administration of the digoxin, the unit secretary informs the nurse that a client w/extensive head and facial injuries has arrived on the unit. Which of the following actions should the nurse take FIRST? 1. Note the time and place the syringe w/the remaining medication on the medication cart 2. Instruct the unit secretary to find another nurse to admit the client 3. Ask the unit secretary to obtain the sheet containing the staff's pager numbers 4. Request that the LPN/LVN continue the administration of the medication

3. Ask the unit secretary to obtain the sheet containing the staff's pager numbers Enables nurse to safely administer the medication, and nurse determines the appropriate person to care for the client; when administering digoxin by direct IV, infuse over a minimum of 5 minutes; use diluted solution immediately; observe IV site; extravasation can l/t tissue irritation and sloughing

The nurse cares for a client diagnosed with Hantavirus pulmonary syndrome (HPS). Which of the following actions by the nurse is MOST appropriate? 1. Set up seizure precautions 2. Assess the client for signs/symptoms of renal failure 3. Assess the client for signs/symptoms of thrombocytopenia 4. Assess the client for signs/symptoms of pneumonia

3. Assess the client for signs/symptoms of thrombocytopenia Caused by HPS; observe for hematuria, hematemesis, bleeding gums, and melena

The home care nurse receives a phone call from the caregiver for a client diagnosed w/AIDS. The caregiver states that she has the flu and is afraid that she is going to give the client an infection. Which of the following actions should the nurse take FIRST? 1. Instruct the caregiver to wear a well-fitting surgical mask that covers the mouth and nose 2. Assess whether the caregiver is frequently washing her hands before providing care 3. Determine if there is someone else available to provide care for the client 4. Inform the caregiver to clean the client's bathroom daily

3. Determine if there is someone else available to provide care for the client Priority is to prevent client's exposure to infection; if that is not possible, actions should be aimed at reducing the client's risk (caregiver wearing mask and frequently washing hands)

The nurse cares for a toddler w/pneumonia caused by Haemophilus influenzae Type B. The nurse will follow which transmission-based precaution? 1. Standard precautions 2. Airborne precautions 3. Droplet precautions 4. Contact precautions

3. Droplet precautions Used w/pathogens transmitted by infectious droplets; droplet precautions indicated for H. influenzae Type B pneumonia in infants and children

An ice storm paralyzes a community during the night. The two nurses on a 24-bed med/surg unit learn that it will be 12 to 15 hours before they can expect the next shift to arrive. Which of the following actions should the nurse take FIRST? 1. Each nurse takes a shower to refresh herself while the other nurse cares for all of the clients 2. Instruct the NAP to begin a.m. cares at 0400 so care can be completed for all of the clients 3. Make a list of all the client's breathing treatments and IV medications for the next 12-15 hours 4. Plan to administer all of the client's PRN medication before they ask for it

3. Make a list of all the client's breathing treatments and IV medications for the next 12-15 hours Priority is determining treatments and medications that are vital to the well-being of the clients

The nurse in the ED is notified that several workers in a local plant have been exposed to radioactive materials. Which of the following actions should the nurse take FIRST? 1. Set up decontamination stations outside the ED 2. Locate the nuclear exposure immediate reaction kit 3. Notify the Director of Nursing the incident 4. Obtain official verification that the incident has occured

3. Notify the Director of Nursing the incident Contact administration to initiate disaster plan

Which action, if performed by a nurse, would be considered negligence? 1. The nurse does not aspirate before injecting heparin SQ into a client's abdomen 2. The nurse removes wrist restraints hourly and puts the client's arm through passive ROM 3. The nurse checks the pedal pulses 2 hours after a client returns from a cardiac catheterization 4. The nurse administers a preoperative injection to a client before removing the client's dentures

3. The nurse checks the pedal pulses 2 hours after a client returns from a cardiac catheterization Checking the pedal pulses after a cardiac catheterization should be done immediately after the procedure and repeated every 15 minutes for several hours to detect changes in circulation; act of omission

Which of the following might alert the nurse to consider an alcohol problem in a client hospitalized for a physical illness? 1. Depression, difficulty falling asleep, decreased concentration 2. Elevated liver enzymes, cirrhosis, decreased platelets 3. Tremors, elevated temp, nocturnal leg cramps, complaint of pain 4. Flu-like symptoms, night sweats, elevated temp, decreased DTR

3. Tremors, elevated temp, nocturnal leg cramps, complaint of pain When a client is admitted for another physical problem to a general medical, surgical, or critical care unit, the nurse many times becomes the case finder and must be alert for subtle symptoms of an alcohol-related problem; client who has several complaints of pain that do not appear to be correlated to the admissions problem requires further investigation; tremors, elevated temp, and pain symptoms are indicative of an alcohol-related problem

The nurse in the outpatient clinic assesses a school-age child brought to the clinic because of a skateboarding accident. Which question should the nurse ask FIRST? 1. "When did the accident occur?" 2. "Were you wearing a helmet?" 3. "How long have you been skateboarding?" 4. "Did you hit your head?"

4. "Did you hit your head?" Injuries caused by skateboarding include wrist injuries and head injuries; priority is to assess for head injury

While working at a local welding plant, a piece of metal penetrates an employee's right eye. The nurse admits the client to the ED. Which of the following responses by the nurse is MOST appropriate? 1. "Can you tell me exactly what happened?" 2. "I thought OSHA required you to wear eye protection" 3. "Did the plant have safety guidelines in place?" 4. "Do you know what type of material entered your eye?"

4. "Do you know what type of material entered your eye?" Some materials (copper, iron, and steel) can result in intense inflammatory reaction; information assists the staff to determine the extent of the injury

The nurse observes that two staff members have been in frequent conflict for the last several weeks. Then nurse decides to schedule a meeting w/both staff members after observing them argue while putting a client back to bed. When meeting w/the staff members, which of the following strategies by the nurse is MOST appropriate? 1. "One ground rule guiding the discussion is no negative comments are allowed" 2. "One of you will speak first, and the other person will refrain from commenting until the first person is done" 3. "I am here to listen. My expectation is for the two of you to work this out" 4. "Each of you will summarize what you hear the other person saying. The other person will then validate the summary"

4. "Each of you will summarize what you hear the other person saying. The other person will then validate the summary" Enhances communication; each party is actively listening and hears the other person's perspective

The elderly relative of the nurse asks, "I need to replace the numbers on my house because pieces of the wood are missing" Which response by the nurse is MOST appropriate? 1. "I am going to schedule you for an appointment w/the ophthalmologist" 2. "You always find something to do to keep busy" 3. "We need to clean your glasses" 4. "I'll check to see if the house numbers are visible"

4. "I'll check to see if the house numbers are visible" Client may have age-related macular degeneration; nurse needs to validate what the client is reporting

During a regional outbreak of the flu, an NAP reports to work on the oncology unit. The nurse notes that the NAP is coughing and has a runny nose and the NAP says that she has an elevated temperature. The NAP tells the nurse that she has no sick leave and is the breadwinner of her family. Which of the following responses by the nurse is MOST appropriate? 1. "Did you take a flu shot?" 2. "You may work at the desk and help the unit secretary with the charts" 3. "I will call one of the other units where clients are less vulnerable" 4. "I'm sorry, but you will have to go home"

4. "I'm sorry, but you will have to go home" During community outbreaks of the flu, should exclude staff w/febrile infections from caring for high risk clients

The ED nursing educator presents an inservice on evidentiary specimen collection in criminal or forensic cases. At the end of the program, participants are asked to state what they remember as the most important points that were made. Which of the following statements made by a participant requires correction by the educator? 1. "Shotgun wadding, bullets, or head shot projections should be wrapped in gauze and put in a cup or envelope" 2. "It is important to save any gravel, soil, grass, twigs, or glass that are on the victim or on the sheets used for transport" 3. "Swabs of both dry and moist secretions should be air-dried prior to placement in the appropriate container" 4. "The victim's clothing should be carefully removed and put into new, clean plastic bags"

4. "The victim's clothing should be carefully removed and put into new, clean plastic bags" Correct that clothing should be removed and bagged; however, the bags should be made of paper, not plastic, b/c bacteria could destroy DNA evidence if plastic bags were used

The nurse cares for clients in the ED. The nurse is approached by transport personnel asking the nurse to sign out a client for transport for MRI. The client states " I was in a car accident and there is something wrong with my left eye" Which of the following responses by the nurse to the transport personnel is MOST appropriate? 1. "I'll call to make sure that they are ready for the client" 2. "Is there a family member who can go with the client to the MRI" 3. "I'll locate the chart to make sure that the physician has ordered the MRI" 4. "You have to talk with the nurse assigned to the client"

4. "You have to talk with the nurse assigned to the client" MRI is contraindicated for clients w/actual or suspected metallinc foreign body in the eye; client was in an auto accident and has the potential for eye injury that involves metal; assigned nurse would know if prior tests have eliminated a possible metal object

The nurse cares for clients on the med/surg unit. After receiving report, which client should the nurse see FIRST? 1. A 32-year-old admitted 8 hours ago w/viral gastroenteritis who is complaining of N/V and diarrhea 2. A 42-year-old 24 hour post-thyroidectomy who is complaining of a HA and pain at the incision site 3. A 50-year-old admitted 72 hours ago for chronic kidney disease w/a UOP of 220 mL in 8 hours and hands and feet that are edematous 4. A 64-year-old admitted yesterday for HTN, HF, and digitalis toxicity w/frequent PVCs

4. A 64-year-old admitted yesterday for HTN, HF, and digitalis toxicity w/frequent PVCs Indicates potassium inbalance; dysrhythmias can rapidly deteriorate to ventricular tachycardia or sudden death

The nurse in the long-term care facility cares for clients during an outbreak of Legionnaires' disease. The nurse recognizes which client is MOST at risk to develop the disease? 1. A 95-year-old client diagnosed w/a fractured right hip 2. An 85-year-old client diagnosed w/a right-sided CVA 3. A 75-year-old client diagnosed w/Alzheimer's disease 4. A 65-year-old diagnosed w/end-stage kidney disease

4. A 65-year-old diagnosed w/end-stage kidney disease Risk factors include advanced age, severe immunosuppression, end-stage kidney disease, diabetes, smoking and pulmonary disease

Four clients arrive in the ED within minutes of one another. Which client should the nurse see FIRST? 1. A client, pale and diaphoretic, who is reporting sudden and severe pain radiating form the flank to the scrotum 2. A client with right lower quadrant abdominal pain of 24 hours duration and which is relieved by drawing the legs up and remaining still 3. A client jaundiced and nauseated, who is reporting pain in the right shoulder and has a temperature of 100 F 4. A client w/sudden epigastric pain and nausea who reports vomiting blood and has an odor of alcohol on the breath

4. A client w/sudden epigastric pain and nausea who reports vomiting blood and has an odor of alcohol on the breath Symptoms of acute gastritis; vomiting and hematemesis may be seen w/gastritis stemming from alcohol abuse; other symptoms are epigastric pain or discomfort, cramping, N/V

The clinic nurse determines that which client requires an immediate intervention? 1. A male client whose fourth and fifth fingers are contracted onto the palm 2. A female client who complains of numbness, tingling, and pain when the nurse taps lightly over the inside of her wrist 3. A female client who reports her fingers hurt and have begun to turn from white to blue to red in cold weather 4. A male client in an arm cast whose fingers and wrist are contracted

4. A male client in an arm cast whose fingers and wrist are contracted Describes Volkmann contracture, which is a type of compartment syndrome caused by obstruction or arterial blood flow to the forearm and hand; cannot straighten fingers, has severe pain, and there may be signs of diminished circulation

The medical unit charge nurse plans assignments of the staff, which consists of three RNs, one LPN/LVN, and one NAP. The charge nurse determines assignments are correct if the NAP is assigned to which of the following clients? 1. A patient with a 5-day-old ostomy requiring stoma care and application of an ostomy apppliance 2. A patient diagnosed in a coma after suffering a head injury requiring cranial nerve assessment and Glasgow coma scale evaluation 3. A patient diagnosed w/a spinal cord injury requiring ROM exercises and instruction about autonomic dysreflexia 4. A patient diagnosed w/COPD and type 1 DM requiring a sputum culture and sensitivity and blood glucose glucometer reading

4. A patient diagnosed w/COPD and type 1 DM requiring a sputum culture and sensitivity and blood glucose glucometer reading Standard, unchanging procedure; RN should instruct NAP about type of specimen to collect, timing, proper collection container, and appropriate labeling of specimen

The nurse supervises the staff caring for clients on the med/surg unit. The nurse observes the student nurse enter wearing a gown, gloves, and a facemask. The nurse determines that the precautions are correct if the student nurse is caring for which of the following clients? 1. An infant diagnosed w/RSV 2. A school-aged child diagnosed w/Hepatitis A 3. A teenager diagnosed w/TSS 4. A teenager diagnosed w/Influenza

4. A teenager diagnosed w/Influenza Droplet precautions used for organisms that can be transmitted by face-to-face contact; door may remain open

The home care nurse plans activities for the day. Which client should the nurse see FIRST? 1. A client who is breastfeeding a 2-day-old infant born 5 days before the due date 2. A client discharged yesterday after IV heparin therapy for a DVT 3. An elderly client discharged from the hospital 3 days ago with pneumonia 4. An elderly client who used all the diuretic medication and is expectorating pink-tinged mucus

4. An elderly client who used all the diuretic medication and is expectorating pink-tinged mucus Symptoms of pulmonary edema; requires immediate attention

The nurse admits a 6-year-old child with an open wound that is MRSA-positive. It is MOST appropriate that the nurse assing this child to which of the following rooms? 1. A semi-private room with a 2-year-old diagnosed with RSV 2. A semi-private room with a 5-year-old diagnosed with acute respiratory virus 3. A private room that is close to the nurse's station 4. Any private room that is available

4. Any private room that is available Requires a private room; semi-private room is acceptable only when there are no other rooms to admit this client, and a MRSA client can room only with another client who is MRSA-positive

The nurse cares for a client diagnosed w/croup. The nurse will follow which transmission-based precaution? 1. Standard 2. Airborne 3. Droplet 4. Contact

4. Contact Acute viral disease of childhood that causes a resonant barking; contact precautions required for all client care activities that require physical skin-to-skin contact or those that require contact w/soiled items in the room or linens

The staff on the med/surg unit consists of two RNs, one LPN/LVN, and one NAP. The charge nurse determines care is appropriate if which of the following tasks is delegated to the NAP? 1. Monitor a client during the first 15 minutes after the RN begins of blood transfusion 2. Determine the patency of a chest tube drainage system for a client w/a pneumothorax 3. Teach a client newly diagnosed w/type 1 diabetes about how to fill out the menu 4. Implement bladder training measures for a client w/urinary incontinence

4. Implement bladder training measures for a client w/urinary incontinence Can be delegated activities related to bladder training; establishing the bladder training program is the responsibilities of the RN

The nurse on the surgical unit receives a call from the OR to administer pre-op medication to a client scheduled for surgery. After administering the pre-op medication, the nurse discovers that the client has not signed the informed consent for the surgery. Which of the following actions should the nurse take NEXT? 1. Notify the physician 2. Ask the client to sign the consent form 3. Transfer the client to the operating room 4. Inform the nursing supervisor

4. Inform the nursing supervisor Nurse should follow chain of command; risks and benefits of the procedure must be explained by the person performing the procedure

The nurse in the pediatric clinic notes that several preschool children have received a single dose of hepatitis B vaccine during infancy. Which of the following actions by the nurse is MOST appropriate? 1. Inform the children's parents that the children must start hepatitis B series over again 2. Note the immunization in the child's history 3. Contact the physician 4. Make an appointment for the children to continue the series of hepatitis B vaccine

4. Make an appointment for the children to continue the series of hepatitis B vaccine Continue immunization series; total of three doses given; should schedule the third dose 3 to 4 months after the second dose; second dose usually 1 to 2 months after first dose

The nurse instructs a student nurse about the correct way to prepare a sterile field. Place the following instructions by the nurse to the student nurse in the correct order from the FIRST action to the LAST. All options must be used. 1. Dispose of the outer wrapper 2. Open wrapper of sterile item 3. Assemble the necessary equipment 4. Place sterile drape on the work surface

4. Place sterile drape on the work surface 3. Assemble the necessary equipment 2. Open wrapper of sterile item 1. Dispose of the outer wrapper - Prevents breaks in sterile technique - Hold drape away from body; lay bottom half of drape on work surface and then the top half of the drape stays sterile and is your sterile field - Appropriate after first two are completed - Prevents accidental contamination of sterile field

The 75-year-old client is admitted w/altered mental status and a UTI. The HCP writes an order for use of a Posey vest restraint. Which action by the nurse is BEST? 1. Perform some of the care so the client doesn't feel that the restraint is a punishment 2. Ask the HCP to change the order to wrist restraints to allow the client some movement in bed 3. Explain the use of the restraint to the client and ask for permission to apply it 4. Reevaluate the client's needs for the restraint every 4 hours

4. Reevaluate the client's needs for the restraint every 4 hours Nurse should assess for and document need for continued use of restraints every 4 hours; order needs to be re-written every 24 hours

The nurse who is caring for clients in the outpatient clinic receives four phone calls. Which call should the nurse return FIRST? 1. A client reports a HA that is unrelieved by medications. The client reports taking two propoxyphene napsylate acetaminophen and two acetaminophen every 4 hours for 3 days 2. A client complains of left ankle pain and swelling that is reddened and warm to the touch. The client states the redness and swelling occurred spontaneously and denies injury to the ankle 3. The parent of a toddler calls to report that the child has a rash and a sore throat 4. The parent of a toddler calls to report that the child swallowed a dime

4. The parent of a toddler calls to report that the child swallowed a dime Nurse should immediately evaluate to determine if the toddler is having respiratory difficulty

The nurse cares for clients on a med/surg unit and determines that several situations need to be addressed. Which situation should the nurse attend to FIRST? 1. An angry adult child is threatening to sue the hospital b/c the confused parent fell out of bed during the previous shift 2. The NAP is 30 minutes overdue from a dinner break in the cafeteria for the third time this week 3. The HCP calls the unit to ask the nurse to obtain a client's latest serum electrolyte results from the lab 4. The spouse of a client reports to the nurse that the client's nose began bleeding after returning from radiation therapy

4. The spouse of a client reports to the nurse that the client's nose began bleeding after returning from radiation therapy Should assess the client to determine amount and cause of bleeding

The nurse prepares to discharge a postpartum client in 1 hour. The client request more peripads, diapers, wipes, and perineal spray. Which of the following responses by the nurse is BEST? 1. I will be glad to get these supplies for you 2. Why don't you stop at the store on the way home? 3. I don't think that you need any more supplies 4. What items do you need during the next hour?

4. What items do you need during the next hour? Provides for client's immediate needs in a cost effective way