Safety and Control

A nurse reinforce teaches a group of police officers about the spread of TB. Which statement by an officer indicates that teaching has been effective?

"I could get TB if I inhale infected droplets when an infected individual coughs."

A client who is bleeding internally needs emergency surgery to stop the bleeding, but refuses treatment. Which are grounds for challenging a client's right to refuse treatment? Select all that apply.

-The client is incompetent. -Compelling reasons exist to overrule the client's wishes.

A client comes to the clinic and is diagnosed with shingles. Which findings confirm this diagnosis? Select all that apply.

-severe, deep pain around the thorax -red, nodular skin lesions around the thorax -fever

The nurse is caring for a client after surgery. The surgeon has written "resume pre-op meds" as an order on a client's chart. What should the nurse do next?

Contact the surgeon for clarification because this is not a complete order.

The nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?

Use the smallest needle possible for injections.

The nurse is gathering data from several children in the clinic with reports of diarrhea. Which child would be at greatest risk for giardiasis?

child that attends group day care

The nurse is managing care for a group of clients on a busy medical-surgical unit. What is the best way for the nurse to prevent errors?

identifying incorrect dosages or potential interactions of ordered medications

A parent of a 9-year-old-child scheduled to have surgery expresses concern about the potential for postoperative infection. A nurse provides the parent with information about the measures taken to maintain surgical asepsis. Typical surgical asepsis involves:

performing a preoperative surgical scrub for at least 3 to 5 minutes.

The nurse is caring for a client with a Jackson-Pratt drain. While emptying the drain, the nurse is splashed with blood. Which of the following actions should the nurse take?

wash affected area with soap and water

A client is scheduled for an electroencephalogram (EEG) after having a seizure for the first time. Which instruction does the nurse provide to the client as preparation for this test?

"Avoid stimulants and alcohol for 24 to 48 hours before the test."

The licensed practical nurse is teaching a client with right-sided weakness proper cane use. Which instruction should the nurse include in her teaching?

"Hold the cane on the opposite side from the injury."

A young adult was told that he had a significant reaction to the Mantoux test. The client asks the nurse what is the meaning of this significant reaction. How does the nurse appropriately respond?

"You have been exposed to tuberculosis."

The nurse is assisting a client with cerebrovascular accident (CVA) with feeding. Which nursing action(s) promote(s) safety when feeding the client? Select all that apply.

-Have the client in a sitting position. -Elevate the head of the bed. -Check the mouth after feeding.

The nurse is caring for a female client who underwent surgery 8 hours ago and is unable to void. When placing an indwelling urinary catheter in this client, the nurse should first advance the catheter how far into the urethra?

2" (5 cm)

A nurse is preparing to administer a preoperative intramuscular (IM) injection a 9-year-old child. Which size needle should the nurse select?

22G, 1-inch

After an instructor has posted assignments, a person claiming to be a nursing student arrives on a unit and asks a nurse for access to the medication records of a client to whom the student nurse has been assigned. The student's only identification (ID) is a laboratory coat with the school's name on it. What is the nurse's most appropriate response?

Ask the student to provide a photo ID for comparison with the names on the assignment sheet.

The skin in the diaper area of a 6-month-old infant is excoriated and red. Which instructions would the nurse give to the parent?

Change the diaper more often.

A nurse is caring for a client who has a history of epilepsy. After the client experiences a generalized tonic-clonic seizure, what is the priority nursing action?

Check the client's vital signs and remove restrictive clothing.

A nurse is supervising a student during medication administration to a client. Which action by the student would cause the nurse to intervene during the med pass at the bedside?

Check the room number and the client's name on the bed.

An 8-year-old child is brought to the clinic with watery eyes and clear nasal drainage that has lasted more than 10 days, without fever. The nurse observes that the child has dark circles under the eyes and a crease above the tip of the nose. Which intervention should be the nurse's priority?

Collect data about potential environmental allergy triggers.

A nurse inadvertently administers 40 mg of propranolol to a client instead of 10 mg. Although the client exhibits no adverse reactions to the larger dose, which action by the nurse would be most appropriate?

Complete an incident or unusual occurrence report.

A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require?

Contact isolation

A client with an indwelling catheter asked the nurse to remove the catheter. Which first intervention is best when removing an indwelling catheter?

Deflate the balloon before removing the catheter.

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?

Demonstrating control over aggressive behavior

The nurse is preparing to discuss administration of a vaginal irrigation with a client. Which step would be appropriate to have the client perform?

Direct the tip of the nozzle toward the sacrum.

A client is receiving antibiotic drug therapy. Which aspect of implementation related to drug therapy would the nurse utilize?

Documenting medications administered

A client is admitted into a medical unit confused and agitated. Which nursing measure should the nurse implement first to keep the client safe?

Encourage family, friends, or a sitter to stay with the client.

A client admitted to the hospital for internal fixation of a fractured left femur is attending physical therapy to learn how to use crutches. After the session, a nurse observes improper crutch use by the client. How should the nurse intervene?

Gently remind the client of the proper technique.

A client is admitted to the hospital for an asthma exacerbation. The nursing history reveals this client was exposed to varicella (chickenpox) 1 week ago. When, if at all, would this client require isolation?

Immediate isolation in a private room is required .

A client is admitted to the emergency department with a closed head injury after being found unconscious. Based on information from the client's neighbor, the staff suspects intimate partner violence. The client has a restraining order against the spouse, but the spouse repeatedly attempts to visit the client. Which action should the nurse take?

Inform hospital security personnel of the restraining order and description of spouse.

The nurse is caring for a client with hypertension. What is the best action for the nurse to take when administering a new blood pressure medication to a client?

Inform the client of the new medication, its name, its use, and the reason for the change.

What is an appropriate nursing intervention for a client with a soft wrist restraint?

Monitoring circulatory status every 15 minutes if the client is agitated, or every 2 hours if the client is calm

What should the nurse do to ensure a safe hospital environment for a toddler?

Move the equipment out of reach.

A nurse is assisting with planning care for a client with retinal detachment. The client has both eyes patched but is alert and oriented. What measure should the nurse include in the care plan to promote safety?

Place the call bell within the client's reach and ensure the client knows how to use it.

The nurse is caring for a client who has a history of falling at home. Which intervention by the nurse reduces the risk of falling while the client is hospitalized?

Placing the call bell close to the client and reminding the client to call for assistance with ambulation

Which nursing intervention takes priority for a client with human immunodeficiency virus (HIV) infection?

Protecting the client from infection

A nurse observes that an alternate personality (a child) of an adult client with dissociative identity disorder (DID) is in control. The client is sitting in the dayroom, interacting with others. Which action would be most appropriate?

Remove the client from the dayroom and reorient in a safe place.

A client is admitted in a disoriented and restless state after sustaining a concussion from a car accident. Which nursing diagnosis takes highest priority in this client's plan of care?

Risk for injury

During a bath, a neonate has a nursing diagnosis of Risk for injury related to slippage while bathing. Which intervention best addresses this nursing diagnosis?

Support the neonate's head and back with the forearm.

The nurse realizes she's 1 hour late in administering a dose of medication for her 4-year-old client. She gives the medication immediately and assesses the client. The client isn't harmed by the delay. Which action should the nurse take next?

The nurse should follow facility procedures for reporting an error.

What nursing intervention should be provided for a client who is experiencing a seizure?

Turn the client to one side.

A client who is homeless is admitted for treatment of a severe infection. The client reports, "I'm allergic to everything." The nurse reviews the client's medical records at that facility and learns that the client has extensive identified medication allergies. What is the best action for the nurse to take?

Use the drug allergy listing in the medical record as a starting point for a full allergy assessment.

A nurse is orienting a new nurse to the labor and delivery unit. Which action by the new nurse regarding a neonate's security requires intervention by the preceptor?

allowing volunteers to return neonates to the nursery

A health care provider and nurse are discussing treatment options with a client diagnosed with severe ulcerative colitis symptoms. Which potential complication requires frequent assessment?

bowel perforation

A client is admitted to the acute psychiatric care unit after 2 weeks of increasingly erratic behavior. The client is unkempt, has lost approximately 9 lb (4 kg), has been sleeping poorly, and exhibits hyperactivity. The client loudly denies the need for hospitalization. What priority intervention will the nurse apply?

decreasing environmental stimulation

After administering an I.M. injection, a nurse should

discard the uncapped needle and syringe in a puncture-proof container.

A client with pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of narcotic analgesic?

document the client's choice and re-assess pain in 1 hour

The nurse is completing a sexual history on a client. The client reports a history of having a sexually transmitted infection (STI) that lies dormant in the body and can reoccur, but does not remember the name. Which STI matches the client's description?

herpes

A physician enters a computer order for a nurse to irrigate a client's nephrostomy tube every 4 hours to maintain patency. The nurse irrigates the tube using sterile technique. After irrigating the tube, the nurse decides that she can safely use the same irrigation set for her 8-hour shift if she covers the set with a paper, sterile drape. This action by the nurse is

inappropriate because irrigation requires strict sterile technique.

The nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is:

keeping the bed in the lowest possible position.

A nurse is caring for a client after a hemorrhoidectomy. Which order would the nurse question on the medical record?

low-fiber diet

An elderly client has been admitted to the medical-surgical unit from the postanesthesia care unit. While the nurse is off the floor, the client falls out of bed and fractures the right leg and right wrist. The nurse finding the client states, "The side rails were down and the bed was in the high position." The client's family files legal charges against the nurse and the hospital. Which charge most accurately reflects the nurse's actions?

negligence

A client is being admitted to the hospital with abdominal pain, anemia, and bloody stools. The client complains of feeling weak and dizzy. The client has rectal pressure and needs to urinate and move their bowels. The nurse should help the client

onto the bedpan.

The clinic nurse is working with a client with dysuria who is prescribed phenazopyridine. The nurse will reinforce the client to expect urine that is what?

orange

A client needs to void 3 hours after a vaginal birth. The nurse implements safety precautions when getting the client out of bed based on an understanding that the client is at risk for which condition?

orthostatic hypotension

A healthcare provider has entered orders for a client with chronic obstructive pulmonary disease (COPD). Which order should the nurse question?

oxygen increased to 3 L/minute if oxygen saturation is less than 94% on room air

A train accident sends a large number of injured passengers to the hospital. The hospital's disaster plan is put into effect. Which nursing action would best serve the hospital in this disaster situation?

perform duties as outlined in the disaster plan

A client in a nursing home is receiving continuous nasogastric (NG) feedings. At the start of the shift, a nurse finds the client turned on the side with the bed flat. The feeding is running with a volumetric pump at 75 mL/hour, as prescribed. The formula container is filled with 150 mL of fluid. Based on this information, which action should the nurse take?

raise the head of the bed (HOB) at least 30 degrees

A client refuses the evening dose of haloperidol and then becomes extremely agitated in the day room while other clients are watching television. The client begins cursing and throwing furniture. The nurse's first action is to:

remove all other clients from the day room.

A nurse is caring for a client with a seizure disorder. This nurse should instruct the client to avoid which activity until the seizures are controlled by medication?

swimming

A nurse places a client who is suspected of having tuberculosis in isolation. Which part of the chain of infection do isolation techniques interfere with?

transmission mode

A nurse is repositioning a client in bed. What should the nurse do to maintain proper body mechanics?

use a wide stance for support

A nurse is reviewing principles of good body mechanics with a student practical nurse. Which technique should be emphasized?

using large muscles in the legs for leverage

The nurse is caring for a client diagnosed with chronic thrombocytopenia. Before discharge, the nurse reinforces which activities to the client to decrease excessive bleeding? Select all that apply.

-Avoid alcohol. -Avoid aspirin and ibuprofen. -Check with your health care provider about taking OTC drugs.

The home health nurse visits an older adult client and their spouse to discuss home safety prior to discharge from the hospital. What information should the nurse focus on to optimize safety?

"It's important to have good lighting and clear, even flooring surfaces."

The nurse is providing care for a pregnant 16-year-old client. The client says that she's concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying:

"Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems."

The nurse is reinforcing education about home care with the parents of a child diagnosed with type 1 diabetes. The nurse determines the education has been successful when the parent makes which of the following statements? Select all that apply.

-"We can dispose of used lancets and insulin syringes in a puncture-proof container such as a bleach bottle." -"I will be sure my child wears a Medic Alert bracelet." -"My child should receive immunizations for influenza and pneumonia."

A client is prescribed ampicillin 125 mg IM every 6 hours to a 10 kg child with a respiratory tract infection. The drug label reads, "The recommended dose for a client weighing less than 40 kg is 25 to 50 mg/kg/day IM or IV in equally divided doses at 6- to 8-hour intervals." The drug concentration is 125 mg/5 mL. Which nursing interventions are appropriate at this time? Select all that apply.

-Determine if the client has allergies to penicillin. -Administer the medication because the dosage is within the recommended range. -Obtain a sputum culture, if ordered, before administering the medication.

A nurse is caring for a client with a history of falls. Which interventions take priority in this client's care? Select all that apply.

-Place the call light within the client's reach. -Keep the bed in the lowest possible position. -Provide immediate response to the client's toileting needs.

A client is receiving oxygen by way of a nasal cannula at a rate of 2 L/minute. How can the nurse promote oxygenation in this client? Select all that apply.

-Position client in Fowler's position. -Decrease anxiety in the client. -Set any part of the ball so it touches the line marked "2."

A nurse is caring for a client who has bacterial conjunctivitis. Which finding would lead the nurse to conclude that treatment for conjunctivitis was effective?

Absence of purulent discharge

The physician orders chest physiotherapy for a client with respiratory congestion. When should the nurse plan to perform chest physiotherapy?

Before meals

A nurse inadvertently transcribes a client's medication order that was written as "Ampicillin 250 mg four times a day" as "Ampicillin 2500 mg four times a day." The nurse gives two doses as transcribed to the client. Another nurse gives one dose before the pharmacist questions the reorder of the medication. What should the two nurses do in this situation?

Both nurses must acknowledge making the medication error.

A nurse is administering morning medications to a client on warfarin. Upon reviewing the laboratory results, the nurse notes a prothrombin time (PT) of 27.3. What should the nurse do?

Hold the medication and notify the health care provider.

A client has a surgical wound with a drain. When cleaning around the drain, the nurse should wipe in which direction?

In a circle, from the center outward

A client presents to the outpatient center for a gastroscopy that reveals redness and inflammation of the stomach indicating acute gastritis. Which action should be included in the immediate management?

Treat the underlying cause of disease.