Safety and Infection Control
The medical center encounters a bomb threat. The emergency response team informs the staff that the threat is legitimate and that clients should start being evacuated. Which of the following clients should the nurse begin evacuating FIRST to the safe designated area? A) Ambulatory clients B) Bedridden clients C) ICU clients D) Infant clients
A) CORRECT: Ambulatory clients have the potential to wander and end up in an unsafe place if not directed correctly
The physician verbally orders a medication for a client during an emergency code. Which of the following should the nurse do? A) Repeat the order back to the physician for confirmation and administer it B) Retrieve the medication and administer it C) Write the order down, retrieve the medication, and administer it D) Read the order to another nurse, have that nurse retrieve the medication, and stay with the client
A) CORRECT: In an emergency code situation, the order can be repeated back to the physician for confirmation and given, as there is another nurse recording events of the code
The hospitalized client is receiving an infusion and the pump has malfunctioned. Which of the following actions by the nurse is the MOST appropriate once the infusion has been stopped and restarted with a functioning pump? A) Place a "Broken" sticker on the malfunctioning pump according to hospital policy, and place the pump in the designated malfunctioning equipment area B) Place the malfunctioning pump in the utility room C) Remove the malfunctioning pump from the client's room and place with other pumps D) Place the malfunctioning pump to the side in the client's room
A) CORRECT: The malfunctioning equipment should be labeled clearly and put in a separate area to be reviewed by the equipment department
The client has a new order for placement of a Foley catheter due to urinary retention. Which of the following should the nurse do before starting the procedure? SELECT ALL THAT APPLY A) The nurse should confirm the client's identity, because a procedure requires proper identification B) The nurse should confirm the client's medical record number via the wristband and order C) Ask the client his or her name only, because this is a procedure and not a medication administration D) The nurse should confirm the client's name via the wristband and order
A) CORRECT: The nurse should confirm the client's identity, because a procedure requires proper identification B) CORRECT: The nurse should confirm the client's medical record number via the wristband and order D) CORRECT: The nurse should confirm the client's name via the wristband and order
An elderly client, who is not oriented to time, place, or person, had a total hip replacement. The client is attempting to get out of bed and pull out the IV line that is infusing antibiotics. the client has bilateral soft wrist restraints and a vest restraint. Which of the following interventions by the nurse are appropriate? SELECT ALL THAT APPLY A) Ask the client if he needs to use the bathroom, and provide range-of-motion exercises every 2 hours B) Document the type of restraint used and assess the need for continued use C) Tie the restraints to the side rails of the bed D) Obtain a new physician order for the restraint every 12 hours E) Observe for correct placement of restraints F) Tie the restraints in a quick release knot
A) CORRECT: Toileting and range of motion exercises should be provided every 2 hours while a client is in restraints B) CORRECT: The client must be assessed frequently to ascertain when restraints can be removed, and this information must be documented E) CORRECT: The nurse should observe for correct placement of restraints F) CORRECT: Restraints should be tied in knots that can be released quickly and easily
The nurse is preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge home. Which of the following instructions should the nurse include? A) "Avoid sharing articles such as razors and toothbrushes" B) "Do not share eating utensils with family members" C) "Limit the time you spend in public places" D) "Avoid eating food from serving dishes shared with others"
A) CORRECT: the human immunodeficiency virus (HIV), which causes AIDS, is concentrated mostly in blood and semen. the client should not share articles that may be contaminated with blood, such as razors and toothbrushes
The nurse is preparing to administer a unit of PRBCs to an anemic client. After obtaining the blood from the blood bank, the nurse must begin administering it within which of the following time periods? A) 15 minutes B) 30 minutes C) 45 minutes D) 60 minutes
B) CORRECT: After obtaining the blood product from the blood bank, the nurse must begin administering the product within 30 minutes
The client is an obese male with decubitus ulcers. Treatment of the ulcers requires frequent turning and repositioning. The nursing unit has a special lift that allows for turning of clients and placement onto a bedpan without any lifting on the part of the staff. The client urgently requests the bedpan. Because the lift apparatus takes a few minutes to set up, which of the following should the nurse do? A) Quickly assist the client onto the bedpan without the lift because he needs to use it urgently B) Encourage the client to try to be patient, and set up the apparatus C) Get the assistance of an aide to help lift the client D) Encourage the client to wear an incontinence brief
B) CORRECT: Encourage the client to wait while the apparatus is set up. It is more important to prevent potential injury to the nurse. Nurses are commonly affected by ergonomic injuries related to lifting and moving clients
The nurse is assessing an elderly client for risk of falls. Which of the following should the nurse collect? A) The facility's restraining policy B) Gait, balance, and visual impairment information C) Psychosocial history D) The facility's environmental safety plan
B) CORRECT: Fall risk should include assessment of gait, balance, and visual impairment
The nurse completes a peripherally inserted central catheter (PICC) line dressing change for a home care client. When removing the PPE, the nurse should do which of the following? A) Remove the mask and then the gloves B) Remove the gloves and then the mask C) Remove only the gloves, there is no need to wear a mask D) Remove only the mask, there is no need to wear gloves
B) CORRECT: Gloves are removed first
The physician orders an MRI of the brain for an adult male client. Which of the following findings in the client's history should the nurse report to the physician? A) Allergy to contrast dye B) Implanted cardiac pacemaker C) Chronic Obstructive Pulmonary Disease (COPD) D) Hernia repair
B) CORRECT: Metallic items, including metallic implants such as a cardiac pacemaker, are contraindicated in an MRI
An older adult has been admitted with diagnosis of stroke and a history of dementia. Which of the following nursing diagnoses has the highest priority for this client? A) Bathing/hygiene self-care deficit B) Risk for injury C) Impaired physical mobility D) Disturbed though processes
B) CORRECT: Older adults with dementia are at risk for injury due to increased risk for falls, because they may not recognize their limitations, despite immobility related to stroke
The nurse discovers a client on the floor in the client's hospital room. After examining the client and assisting him safely back to bed, which of the following should the nurse do FIRST? A) File an incident report B) Put the bed alarm back on C) Institute a client observer to sit with the client and prevent further falls D) Notify the nurse manager
B) CORRECT: Putting the bed alarm back on is the most appropriate first step to promote immediate safety of the client
The nurse discovers that the last dose of intravenous antibiotic administered to a client was the wrong dose. Which of the following should the nurse do? A) Document the event in the client's medical record only B) File an incident report, and document the event in the client's medical record C) Document in the client's medical record that an incident report was filed D) File an incident report, but don't document the event in the client's medical record, because information about the incident is protected
B) CORRECT: The event should be filed in an incident report and in the client's medical record
The nurse is preparing to test a client who has allergies from an unknown cause. Which of the following tests should the nurse perform? A) Tzanck test B) Patch test C) Rinne test D) Stress test
B) CORRECT: the patch test identifies the cause of allergic contact sensitization and is indicated in clients with suspected allergies or allergies from an unknown cause
In the emergency room, the nurse assesses a 4 yo child suspected of having measles. Which of the following kinds of precautions should the nurse initiate? A) Contact precautions B) Droplet precautions C) Airborne precautions D) Reverse isolation
C) CORRECT: Airborne precautions are used to prevent the transmission of infectious agents that remain infectious over long distances when suspended in the air
A female client comes to the emergency department complaining of vaginal discharge, irritation of the vagina, and the need to urinate often. The nurse suspects a sexually transmitted disease (STD), and the physician orders diagnostic testing of the vaginal discharge. Which of the following STDs does the nurse know must be reported to the Department of Public Health? A) Genital herpes B) Human papilloma virus C) Gonorrhea D) Chlamydia
C) CORRECT: Gonorrhea must be reported to the Department of Public Health
The nurse has just administered insulin to a diabetic client. In which of the following way should the nurse dispose of the needle? A) Re-cap the needle and discard it in the nearest puncture resistant container B) Re-cap the needle and discard it in the nearest biohazard container C) Discard the needle in a puncture resistant container D) Break the needle and discard it in the nearest puncture resistant container
C) CORRECT: Needles and sharps should be placed in the nearest puncture resistant container
The nurse witnesses another nurse, wearing a gown and gloves, enter a client room labeled "Airborne Precautions". Which of the following actions by the witnessing nurse is MOST appropriate? A) Notify the nurse manager to discuss policies with the other nurse B) Ask a physician to give a presentation on which precautions require which type of personal protective equipment (PPE) C) Remind the other nurse that she needs a mask in addition to a gown and gloves for airborne type precautions D) Ask the other nurse to look up the policy about precautions
C) CORRECT: Remind the other nurse that she needs a mask in addition to a gown and gloves for airborne type precautions
The nurse is administering nightly medications, which include an anticoagulant and a stool softener. Which of the following should the nurse do FIRST before administering the medication? A) Scan the medication label and the client's wristband B) Ask the client his or her name to properly identify this client as the one for whom the medications were ordered C) Match the client's date of birth and name on the client's wristband with the same information on the medication order D) Match the client's name and room number with the medication order
C) CORRECT: The 2009 National Patient Safety Goals require using a minimum of two patient identifiers as a means to promote the safest care and to prevent medication errors
The client is found on the floor by the nursing assistant. Once the client is safe, which of the following should the nurse do next? A) Document the event in the client's medical record and file an incident report B) File an incident report only C) Document the event in the client's medical record and have the nursing assistant file an incident report D) Document the event in the client's medical record only
C) CORRECT: The event should be documented in the client's medical record and the nursing assistant should file an incident report
the nurse is developing a care plan for a client with hepatitis C. The nurse knows that the primary route of transmission of this hepatitis virus is which of the following? A) Contaminated food B) Feces C) Blood D) Sputum
C) CORRECT: The hepatitis C virus is transmitted through blood and parenteral routes
the client has experienced multiple episodes of hyperglycemia not manageable by subcutaneous insulin injections. The client has an active order for infusion of an insulin drip for glycemic management to be discontinued at bedtime, after which the client is NPO. The client's most recent blood sugar level, taken at 3pm was 60. which of the following is the MOST appropriate? A) The nurse should follow the order and allow the insulin to infuse until bedtime B) The nurse should recheck the client's blood sugar C) The nurse should bring this blood sugar level to the physician's attention and discuss stopping the infusion D) The nurse should seek advice from other nurses
C) CORRECT: the most appropriate action is to contact the physician and discuss stopping the infusion, based on the last blood sugar level
The nurse is preparing to administer a tuberculin (Mantoux) skin test to a client suspected of having tuberculosis (TB. The nurse knows that the test will reveal which of the following? A) How long the client has been infected with TB B) Active TB infection C) Latent TB infection D) Whether the client has been infected with TB bacteria
D) CORRECT: A tuberculin skin test is performed to determine if a person has ever had TB
Which of the following actions by the nurse is the MOST effective means of preventing infection? A) Washing hands after client contact B) Washing hands after removing gloves C) Hand hygiene between clients D) Hand hygiene before entry to a client's room and upon exit of a client's room
D) CORRECT: Hand hygiene should occur before entry and upon exit of all client care transactions
The nurse is making a home visit to an elderly client during the winter. The nurse notices upon arrival that the client has the oven turned on with the oven door open, and is using it as a form of heat. Which of the following actions by the nurse is MOST appropriate? A) Take care of the client's medical needs and do not get involved in the client's private matters B) Shut the oven off and continue with the home visit C) Report the event to the local Fire Department D) Have a meeting with the client and family and warn them of the fire and safety risks of using the oven for heat
D) CORRECT: Have a meeting with the client and family and warn them of the fire and safety risks of using the oven for heat
The nurse is preparing to discharge a client with rheumatic heart disease who is recovering from endocarditis. Which of the following statements from the client indicates that the client understands the teaching? A) "I am so glad I don't need any more antibiotics now that I'm feeling better" B) "I can restart my exercise program in a day or two" C) "I will watch for signs of relapse the first few days after discharge" D) "I will inform my dentist should I ever need any dental work"
D) CORRECT: Susceptible clients must understand the need for prophylactic antibiotics before, during, and after dental work
Two nurses are preparing to lift a client up in bed. Which of the following should the nurses do to help avoid injuring their backs? A) Bend from the waist B) Lift with the back, not with the legs C) Lower the head of the bed to about 30 degrees, if the client can tolerate it D) Make certain the bed is in a reasonably high position
D) CORRECT: The bed should be in a reasonably high position so the nurses do not have to lean
The adult children of a hospice home care client inquire about whether it is safe to hug their mother, because she has a methicillin resistant Staphylococcus aureus (MRSA) infection in the past. Which of the following statements by the children would indicate a need for further teaching by the nurse? A) "We should wash our hands frequently" B) "We should use hand sanitizer" C) "Those of us with poor immune systems should be extra careful" D) "We should wear gowns and gloves at all times when having contact with our mother"
D) CORRECT: The family dose not have to wear gowns and gloves when interacting with their mother. the infection occurred in the past; even if it was active, gowns and gloves would not be required. Staff wear PPE to prevent spreading these types of infections to other clients
The nurse is preparing to administer packed red blood cells (PRBCs) to a client. Arrange the following steps in the order the nurse should perform them. ALL OPTIONS SHOULD BE USED A) Explain the procedure to the client B) Obtain the client's vital signs C) Assess that the client has a blood bank identification armband D) Obtain the PRBCs from the blood bank according to hospital policy and perform a visual check of the blood E) Perform a bedside identification and blood product verification by two licensed individuals F) Verify the physician order G) Prime the transfusion tubing with a 0.9% sodium chloride solution
F) Verify the physician order C) Assess that the client has a blood bank identification armband A) Explain the procedure to the client B) Obtain the client's vital signs G) Prime the transfusion tubing with a 0.9% sodium chloride solution D) Obtain the PRBCs from the blood bank according to hospital policy and perform a visual check of the blood E) Perform a bedside identification and blood product verification by two licensed individuals
