Safety

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The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the distal end of the IV tubing to a needleless device, the tubing drops and hits the top of the medication cart. Which is the appropriate action by the nurse?

The nurse is preparing for the administration of ribavirin (Virazole) to a child with respiratory syncytial virus. Which supplies will the nurse obtain for the administration of this medication?

The nurse administers medications to the wrong client. During the investigation of the incident, it was determined that the nurse failed to check the client's identification bracelet before administering the medications. The nursing supervisor evaluates the situation and determines that the nurse can be guilty of negligence because negligence is correctly characterized by which statement?

A client has an arteriovenous (AV) shunt in place for hemodialysis. The nurse should take which priority precaution, knowing that bleeding is a potential complication?

The nurse manager asks a licensed practical nurse to work on her day off because of a short-staffing problem. The licensed practical nurse has already made plans and does not want to work on the day scheduled to be off. Which response by the licensed practical nurse to the nurse manager is assertive?

"I have planned to take the day off and will not be able to work on that day."

The nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further teaching?

"I need to be sure to place my cup of coffee on the counter."

The nurse has instructed a client diagnosed with tuberculosis (TB) about how to prevent the spread of infection after discharge. The nurse determines that the client needs further teaching if the client makes which statement?

"I should use disposable plates, forks, and knives."

The nurse is providing instructions to a client with a diagnosis of scabies regarding the administration of crotamiton (Eurax). Which statement by the client indicates an understanding regarding the application of this medication?

"I will massage the medication into the skin from my chin downward and apply a second application in 24 hours, followed by a cleansing bath 48 hours after the second application."

A resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." An appropriate response by the nurse is which?

"I'm glad you told me that. Let's have a cup of coffee and you can tell me about your father."

A client with possible rib fracture has never had a chest x-ray. The nurse should plan to tell the client which statement about the procedure?

"It is necessary to remove jewelry and any other metal objects."

A sexually active 20-year-old client has developed viral hepatitis. Which statement made by the client would indicate a need for teaching?

In preparing to care for a hospitalized child with a diagnosis of measles (rubeola), which supplies should the nurse bring to the child's room to prevent the transmission of the virus?

The emergency department nurse is reinforcing discharge instructions to the parents of a 2-year-old child who sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have correctly understood the teaching when they make which statement?

The nurse discusses emergency nursing measures that are implemented at the site of an injury with a nursing student. Which initial action does the nurse tell the student to perform in the event of carbon monoxide poisoning?

The nurse employed in a long-term care facility calls the health care provider (HCP) regarding a new medication prescription because the dose prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which action should the nurse take?

The nurse is assisting in planning care for a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention should the nurse include in the plan of care?

The nurse is caring for the client who is going to have an arthrogram using a contrast medium. Which data collected by the nurse should be of highest priority?

The nurse is explaining The Joint Commission's (TJC's) universal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery to a group of nursing students. The nurse explains that site marking involves which action?

The nurse is preparing a client for a magnetic resonance imaging (MRI) examination. Which action by the nurse is important?

The nurse is assisting in preparing a plan of care for a child who is being admitted to the pediatric unit with a diagnosis of seizures. Which components should be included in the plan of care? Select all that apply.

1. Maintain the bed in a low position. 3. Pad the side rails of the bed with blankets. 4. Place the child in a side-lying lateral position if a seizure occurs. 5. Protect the child's head, body, and extremities if a seizure occurs.

The licensed practical nurse knows that which items are examples of common law? Select all that apply.

1. Malpractice 2. Informed consent 5. Client's right to refuse treatment

The nurse shares with a client that violation of a civil law usually results in which type of penalty? Select all that apply.

1. Monetary fine 2. Public service 3. Replacement of property

The nurse is monitoring the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse prepares to implement bleeding precautions if the child becomes thrombocytopenic and the platelet count is less than which value?

The nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid, and the client's affect is belligerent. Based on these observations, the nurse's immediate priority of care is which?

The nurse working in the day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center and assists in planning activities that will meet the child's needs. The nurse understands that the priority consideration in planning activities for the child is to ensure which need is met?

To ensure a safe environment for a child admitted to the hospital for a craniotomy to remove a brain tumor, the nurse should include which in the plan of care?

The nurse on the day shift receives client assignments for the day. Which assigned client should the nurse check first?

A client who was admitted during the night because of a severe exacerbation of asthma

The nurse must choose a roommate for a client who is in a state of starvation due to anorexia nervosa. The nurse should avoid choosing which client as a roommate for the client with anorexia nervosa?

A client with pneumonia

The nurse is assigned to care for a child with hypertrophic pyloric stenosis scheduled for a pyloromyotomy. In which position should the nurse place the child during the preoperative period?

Prone with the head of the bed elevated

An outbreak of illness has occurred in a community and is suspected to be related to food ingestion. A community health nurse places priority on which intervention?

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis (TB). The nurse should plan to wear which items when performing this care?

The nurse is performing oral care for a newly admitted client who is undergoing chemotherapy for thyroid cancer. The nurse should take which actions while performing oral care? Select all that apply.

2. 3. 4.

Which are the best ways for the nurse to avoid malpractice? Select all that apply.

2. 4. 5.

The nurse enters the room to find that the client's trash can is in flames. The nurse should take which action first?

A client with tuberculosis (TB) asks the nurse about precautions to take after discharge from the hospital to prevent transmitting infection to others. The nurse develops a response to the client's question, based on which understanding?

The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply.

1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3.Wearing a film (dosimeter) badge when in the client's room 4. Wearing a lead apron when providing direct care to the client

The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client?

A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

A nursing instructor asks a nursing student to define a critical path. Which statement made by the student indicates a need for further teaching regarding critical paths?

"They are nursing care plans and use the steps of the nursing process."

A nursing instructor asks a nursing student to describe the standards of care formulated by the American Nurses Association. Which statement by the student indicates an inaccurate description of these statements?

"They are specific guidelines."

A licensed practical nurse (LPN) is collecting data on a child and notes the presence of old and new bruises on the child's back and legs. The LPN suspects physical abuse and reports the findings to the registered nurse knowing that which action is necessary?

The nurse employed in a long-term care facility is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)?

The nurse is assigned to care for a client being admitted to the nursing unit from the emergency department who attempted suicide by ingesting several sleeping pills. The nurse implements which priority action when the client arrives to the unit?

The nurse is present at a disaster scene and is participating in the triage of victims. Which color tag should be assigned to a victim with evidence of open pneumothorax?

The nurse is taking the nursing history of a client with silicosis. The nurse checks whether the client wears which item during periods of exposure to silica particles?

The nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further teaching?

"I will place a steam vaporizer in my child's room."

The nurse has provided instructions to the mother of a child who has been diagnosed with bacterial conjunctivitis. Which statement by the mother would indicate the need for further teaching?

"It is okay to share towels and washcloths."

The nurse is preparing to clean up a blood spill on the client's bedside table. The spill occurred when a blood tube containing the client's blood specimen broke. The nurse avoids doing which action when cleaning up the blood spill?

The nurse is caring for a child who returned from tonsillectomy surgery 30 minutes ago and enters the room for routine monitoring to see the child repeatedly and rapidly swallowing. Using the SBAR (Situation, Background, Assessment, Recommendation) technique, which statements and/or questions should the nurse include in the conversation with the health care provider? Select all that apply.

3. "Could you please come assess the child as soon as possible?" 4. "I am concerned that the child is bleeding from the surgical sites." 5. "Two minutes ago, I entered the child's room for routine monitoring and observed that she was swallowing repeatedly and rapidly." 6. "Hello, this is Maria on the third floor. I am the nurse caring for Ella Smith, the 6-year-old child in room 342 who returned 30 minutes ago from a tonsillectomy."

A client receives meperidine (Demerol) by the intramuscular route. Thirty minutes after receiving the medication, the client develops signs of an allergy to the medication. The client's temperature is 101° F, and the skin is warm and flushed with a notable rash on the chest and back. The nurse further assesses the client and contacts the registered nurse, who then contacts the health care provider. The nurse completes an incident report and accurately documents which?

A nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse must assign four clients and has a licensed practical nurse (LPN) and three unlicensed assistive personnel (UAP) on a nursing team. To which client should the nurse assign the LPN?

The nurse is newly employed in a health agency. The nurse is told that the decision-making process of the organization is based on a centralized structure. The nurse determines that this means that the authority to make decisions is vested in whom?

A few individuals such as the board of directors

The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside?

A pair of scissors

The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous (IV) route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?

A platelet count of 40,000/mm3

The licensed practical nurse (LPN) enters a client's room and finds the client sitting on the floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and health care provider (HCP) are notified of the incident. Which is the next nursing action regarding the incident?

Document a complete entry in the client's record concerning the incident.

A client with right leg hemiplegia is experiencing difficulty with mobility. The nurse determines that the family needs reinforcement of teaching if the nurse observes which action by the family?

Encouraging the client to stand unassisted on the leg

A client reports having had two bowel movements this morning and refuses a dose of docusate sodium (Colace). After appropriately charting in the medication administration record, which action should the nurse take?

Make a notation regarding the client's refusal in the nurse's notes.

A client with a perforated gastric ulcer is scheduled for emergency surgery. The client cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which action in the care of this client?

Obtain telephone consent from the family member witnessed by two persons.

The nurse is reinforcing instructions to a client with chronic vertigo. The nurse stresses the importance of which safety measure to prevent injury or exacerbation of symptoms?

Removing throw rugs and clutter in the home

The nurse has a prescription to give a first dose of hydrochlorothiazide (HCTZ) to an assigned client. The nurse should question the prescription if the client had a history of allergy to which item?

Sulfa drugs

The nurse is observing an unlicensed assistive personnel (UAP) talk to a client who is hearing impaired. The nurse should intervene if which action is performed by the UAP during communication with the client?

The UAP speaks directly into the impaired ear.

A client is being discharged to home following spinal fusion with insertion of rods. For which home environment situation should the nurse suggest a consultation with the continuing care nurse?

The bedroom and bath are on the second floor of the home.

A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. How should the nurse tell the client to provide greater reassurance?

The cane has a flared tip with concentric rings to provide stability.

A client has been taught to use a walker to aid in mobility following internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if which action is noted?

The client advances the walker with reciprocal motion.

A resident in a long-term care facility refuses a medication that has been prescribed. The nurse takes appropriate action after considering which fact?

The client cannot be forced to take the medication.

The nurse is collecting data from a client and is observing the client ambulate with the use of a cane. For which client action, when observed, should the nurse intervene and suggest a physical therapy referral?

The client moves the cane and the unaffected side together.

A child is brought to a clinic after developing a rash on the trunk and on the scalp. The parents report that the child has had a low-grade fever, has not felt like eating, and has been generally tired. The child is diagnosed with chickenpox. Which statement by the nurse is accurate regarding chickenpox?

The communicable period is 1 to 2 days before the onset of the rash to 6 days after the onset and crusting of lesions.

The nurse is planning care for the client with hemiparesis of the right arm and leg. Where should the nurse plan to place objects needed by the client?

Within the client's reach, on the left side

The nurse is giving a client a bed bath and drops the towel on the floor. The nurse should take which action?

A client in the emergency department reports right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse should question which prescriptions? Select all that apply.

1. 2.

Which nursing interventions are most helpful when caring for a client who is displaying signs/symptoms of panic level anxiety? Select all that apply.

1. 2. 4.

The nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse should avoid which intervention in the plan of care?

The nurse is caring for a client with an eating disorder and knows that which signs/symptoms indicate that the client is dealing with anorexia nervosa? Select all that apply.

1. Lanugo 2. Amenorrhea

The nurse posted a comment on a social media site that was unflattering to another nurse. Which accusations can the second nurse bring against the first nurse? Select all that apply.

1. Libel 4. Defamation

The nurse in a women's health clinic is reinforcing instructions to a client that is being treated for pelvic inflammatory disease (PID). Which information would be essential for the nurse to reinforce before discharge? Select all that apply.

1. Get plenty of rest and increase fluid intake. 2. Refrain from sexual activity for 3 weeks. 5. Inform your sexual partner of the need for treatment, even if no symptoms are present.

The nurse is told in intershift report that a client has been appointed a legal guardian. The nurse looks for what evidence that supports this information?

The community health nurse has completed a teaching session about anthrax with members of the community. The licensed practical nurse reinforcing the teaching tells those attending that anthrax can be transmitted via which routes? Select all that apply.

1. Skin 3. Inhalation 4. Gastrointestinal

The nurse reinforces instructions to a client diagnosed with impetigo. Which statement by the client indicates a need for further teaching?

The nurse is caring for a client who has just died. Which end-of-life information needs to be documented in the client's medical record? Select all that apply.

1. Time and date of death 2. Time of body transfer and destination 4. Name of health care provider certifying death 5. Medical tubes, devices, or lines left in the body

The nurse interprets that a client diagnosed with glaucoma needs information about the expected effects of this condition when the client makes which statement?

The nurse enters a client's room, and the client immediately demands to be released from the hospital. On review of the client's record, the nurse notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that the admission was a voluntary admission. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?

The nurse observes an outburst by a client with a history of schizophrenia, during which the client uses extreme foul language. Which appropriate documentation should the nurse make for this occurrence?

The nurse is assessing a client with bipolar disorder who is taking lithium carbonate and who has a lithium level of 1.7 mEq/L. The nurse would expect to find which sign/symptoms of lithium toxicity associated with this level? Select all that apply.

2. Incoordination 4. Mental confusion 5. Muscle hyperirritability

The nurse prepares the plan of care for a client with late-stage Alzheimer's disease who resides in a long-term care facility. Which would be priority concerns to include? Select all that apply.

2. Risk for injury 4. Risk for infection 5. Risk for aspiration 6. Impaired verbal communication

The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)?

A client who requires frequent ambulation

The nurse in charge of a rehabilitation center is planning the client assignments for the day. Which client should the nurse assign to the unlicensed assistive personnel?

A client on strict bed rest and a 24-hour urine collection

The nurse is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)?

A client requiring frequent ambulation with a walker

The nurse is providing instructions to a pregnant client with genital herpes about the measures that need to be implemented to protect the fetus. Which instruction should the nurse provide to the client?

A cesarean section will be necessary if vaginal lesions are present at the time of labor.

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. The nurse's most important aspect of care is to maintain client safety and do which?

Assign a staff member to the client who will remain with him or her at all times.

The nurse is caring for a client who has hand restraints. How often should the nurse assess the skin integrity of the restrained hands?

Every 30 minutes

The nurse is assisting in preparing a teaching plan for a client with Ménière's disease. The nurse places highest priority on teaching the client information related to which information?

Safety

The nurse is caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding preventing the transmission of the infection to the other children in the family and the other household members. Which instructions should the nurse reinforce to the mother?

Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through the saliva.

A client will be undergoing a colonoscopy in the morning. Which task is appropriate to delegate to the unlicensed assistive personnel?

Answering the call light promptly after the enema has been given

Which nursing action would avoid pressure on the popliteal nerve when applying the safety strap across the client's legs on the operating table?

Apply the safety strap 2 inches above the knees.

The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included?

As-needed medications given that shift

A client with Parkinson's disease is developing dementia. Which action should the nurse plan to assist the client in maintaining self-care abilities?

Break down activities into small steps.

After weeks of witnessing a man's deterioration and subsequent death from liver failure, his family disagrees about performing an autopsy. Which criterion does the nurse use to determine if the autopsy can proceed?

Determination by the client's son

The nurse reinforces instructions to the parents of a newborn infant regarding car travel and safety seats. Which information related to the safety of the infant is correct?

Restrain in a car seat in the back seat in a semireclined, rear-facing position.

The nurse is checking a peripheral intravenous (IV) site and notes blanching, coolness, and edema at the site. The nurse should do which first?

Remove the IV.

The nurse is assisting in reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which data would indicate a negative variance?

The presence of dysrhythmias in a client with a myocardial infarction

The nurse is observing a nursing student preparing to suction a pediatric client through a tracheostomy. The nurse intervenes if the student verbalizes which intention?

To apply continuous suction when inserting the catheter

A client is admitted to the psychiatric unit following a serious suicidal attempt by a drug overdose. Which action should the nurse implement?

The registered nurse has written an outcome statement of "Client will feel less anxious by the end of session" for a client with generalized anxiety disorder. Which interventions should the licensed practical nurse use to assist this client in meeting this goal? Select all that apply.

1. 3. 4.

A licensed practical nurse has decided to purchase disciplinary defense insurance and is aware that this type of insurance would provide which type of benefits? Select all that apply.

1. 3. 5.

The nurse is caring for an elderly Hispanic client who is a migrant farm worker and has been admitted for asthma. The nurse is unfamiliar with the cultural practices and beliefs of the client's home land. Which questions are appropriate for the nurse to ask when caring for this client? Select all that apply.

1. 4. 5.

The nurse has just finished taking a course on disaster preparedness. Which statements by the nurse indicate that the teaching has been effective? Select all that apply.

1. "Nurses test plans by participating in disaster drills." 3. "Nurses play key roles before, during, and after a disaster." 5. "Nurses assist in developing internal and external emergency response plans."

The nurse determines that the neutropenic client needs further teaching if which statement is made by the client?

"I will include plenty of fresh fruits in my diet."

A pregnant human immunodeficiency virus (HIV)-positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. Which statement by the woman indicates that additional guidance is needed?

"I will breastfeed, especially for the first 6 weeks postpartum."

Which safety measures that should be implemented when working in the newborn nursery? Select all that apply.

1. Adhere to standard precautions. 5. The parents should be instructed to not release their infant to anyone wearing improper identification. 6. The mother should be fingerprinted and the infant should be footprinted on the identification card before removing the infant from the delivery room.

Which factors should the nurse consider when developing a critical incident stress debriefing (CISD) plan for employees of a level 1 trauma center? Select all that apply.

1. CISD promotes effective coping strategies. 2. CISD occurs in small group settings for staff. 4. CISD may help prevent posttraumatic stress disorder. 5.CISD is only one component of a much larger stress management program.

Methenamine is prescribed for a client with a gram-positive urinary tract infection. The nurse questions the prescription if which preexisting disorder is noted in the client's record?

Cirrhosis

Which infection control method should be the priority to include in the plan of care to prevent hepatitis B in a client considered to be at high risk for exposure?

Hepatitis B vaccine

The licensed practical nurse (LPN) employed in a long-term care facility is asked to assist in planning implementation of a change in the method of documentation system in the nursing unit. Many problems have occurred as a result of the present documentation system, and the nurse manager determines that a change is required. The LPN understands that which is the initial step in the process of change?

Identify the inefficiency that needs improvement or correction.

The nurse receives a telephone call from a male client who states that he wants to kill himself and has a bottle of sleeping pills in front of him. Which would be the best response by the nurse?

Keep the client talking and signal to another staff member to send help to the client.

The nurse is assisting in developing a plan of care for an older client to prevent a fall. Which action would be least likely to prevent a fall?

Keeping the bathroom light off at nighttime

The nurse is reviewing the laboratory results of a child with aplastic anemia and notes that the white blood cell (WBC) count is 2000 cells/mm3, and the platelet count is 150,000 cells/mm3. Which nursing intervention should the nurse incorporate into the plan of care?

Maintain strict isolation precautions.

The nurse obtains a prescription from the health care provider to restrain a client using a jacket (safety) restraint and instructs the unlicensed assistive personnel (UAP) to apply the restraint. Which observation, if made by the nurse, should indicate unsafe application of the restraint?

The nurse reinforces home care instructions with a client diagnosed with impetigo. Which statement indicates the need for further teaching about the measures that will prevent the spread of infection?

A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed linens changed. Which should the nurse wear to perform these tasks?

A health care provider writes a prescription to apply a heating pad to a client's back. The nurse implements the prescription and avoids which action?

A licensed practical nurse (LPN) has received the assignment for the day shift. After making rounds and checking all of the assigned clients, which client will the LPN plan to care for first?

The nurse is assisting in admitting a client with schizophrenia to an acute-care inpatient psychiatric unit from the emergency department; however, the client refuses admission. Which intervention should the nurse implement?

The nurse is assisting in reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which indicates the need for further action and analysis?

A 1-year-old infant is admitted to the hospital for control of tonic-clonic seizures. The nurse helps minimize the infant's risk for injury by implementing which interventions? Select all that apply.

2. 3. 4.

A client is admitted to the hospital with a diagnosis of neutropenia. Which interventions should the nurse include in planning care for this client? Select all that apply.

2. 3. 4.

Which safety measures should be implemented at delivery and when working in the newborn nursery? Select all that apply.

2. 4. 5.

The licensed practical nurse is considering leaving the nursing profession after caring for multiple clients who have been diagnosed with conditions that have poor outcomes. Which measures would most likely assist the nurse in relieving this distress? Select all that apply.

2. 5.

The nurse is having a therapeutic discussion with a client and knows that which statements by the client should be immediately reported to the charge nurse? Select all that apply.

2. "I hid my silverware from dinner last night." 5. "I know that by this time tomorrow all my troubles will be over."

The nurse should plan to reinforce instructions to which client's about the risk for transmission of disease through blood and sexual contact? Select all that apply.

2. A client diagnosed with hepatitis B virus 3. A client diagnosed with hepatitis C virus 6. A client diagnosed with human immunodeficiency virus (HIV)

A woman who is 36 weeks pregnant arrives at the labor and delivery unit complaining of vaginal bleeding. Which signs/symptoms would indicate that the client's bleeding is caused by placenta previa? Select all that apply.

2. Bright red vaginal bleeding 3. Lack of uterine contractions

A nurse lawyer provides an education session to the nursing staff regarding client rights. The nurse asks the lawyer to describe an example that may relate to invasion of client privacy. Which nursing action indicates a violation of client privacy?

The day nurses in a psychiatric unit are receiving report from the night shift. During report, a client approaches the nurses' station, becomes very loud and angry, and demands to be seen by the health care provider immediately. Which nursing intervention is appropriate?

The nurse discovers that one of her assigned clients is bleeding excessively from an abdominal incision. The nurse gives specific prescriptions to an unlicensed assistive personnel (UAP) to attend to the other clients and tells another nurse to call the health care provider immediately. In this situation, the nurse is implementing which leadership style?

The nurse is caring for a postoperative client who has been NPO and the health care provider has prescribed a clear liquid diet. In planning to initiate this diet, which priority item should the nurse place at the client's bedside?

The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS) who has Pneumocystis jiroveci pneumonia. In planning infection control for this client which should be the appropriate form of isolation to use to prevent the spread of infection to others?

A nurse planning care for a client with hepatitis plans to meet the client's safety needs by performing which action?

Several clients are awaiting treatment in an outpatient mental health crisis treatment center. Which client should be treated first?

A client who says that voices sponsored by the FBI are telling him to stab his roommates

The nurse is collecting data from a prenatal client. The nurse determines that which places the client in the high-risk category for contracting human immunodeficiency virus (HIV)?

A history of intravenous (IV) drug use in the past year

The nurse receives a client in the surgical unit who was transferred from the postanesthesia care unit. The nurse checks the client for what data first?

A patent airway

The nurse is caring for an 18-month-old child who has been vomiting. The appropriate position to place the child during naps and sleep time is which?

A side-lying position

The nurse responds to an external disaster (a mass casualty event) that occurred in a large city when a building collapsed. There are numerous victims that require treatment. Which victim should the nurse attend to first?

A victim with a partial amputation of a leg who is bleeding profusely

Acetylsalicylic acid (aspirin) is prescribed for a child with rheumatic fever (RF). The nurse should question this prescription if the child had documented evidence of which condition?

A viral infection

The nurse is assigned to care for a client experiencing episodes of postural hypotension. Which action should the nurse take to ensure safety while transferring the client from the bed to the chair?

Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.

A client with a diagnosis of cystitis has an indwelling urinary catheter and is being cared for by an unlicensed assistive personnel (UAP). The nurse observes the UAP care for the client and intervenes if the UAP performs which action?

Allows the drainage tubing to rest under the leg

The nurse is preparing to feed a client who is at risk for aspiration. The nurse assesses the client and uses a penlight and tongue blade to check the mouth and cheeks for pockets of food. Which action does the nurse take next? Refer to video. Click on the Question Video button to view a video showing preparation procedures.

Places the client in an upright position

The nurse is caring for a hospitalized infant with bronchiolitis. Diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which should be the appropriate nursing action?

Plan to move the infant to a room with another child with RSV.

The nurse is reviewing the health care provider's prescriptions written for a client admitted with acute pancreatitis. Which health care provider prescription should the nurse verify if noted in the client's chart?

Position the client supine and flat.

The nurse is developing a plan of care for a child with autism. The nurse should identify which priority problem for this child?

Risk for injury

The nurse is caring for a client with depression in the mental health unit who is refusing to take the prescribed oral antidepressant. Which are the nurse's best actions to this client's medication refusal? Select all that apply.

1. Notify the health care provider. 2. Document the refusal of medication. 3. Ask the client why he is refusing the medication.

A client with moderate depression who was admitted to the mental health unit 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by taking which action?

Increasing the level of suicide precautions

The client is hospitalized for the insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. Which is the immediate nursing action?

Pick up the implant with long-handled forceps and place into a lead container.

The nurse is caring for a client who is on airborne precautions. The nurse notes that the client is scheduled for a magnetic resonance imaging (MRI) test. Which nursing action would be most appropriate in preparing the client for the test?

Place a surgical mask on the client for transport and for contact with other individuals.

A male client is diagnosed with urethritis caused by chlamydial infection. The unlicensed assistive personnel (UAP) assigned to the client asks the nurse what measures are necessary to prevent a contraction of the infection during care. Which instruction should the nurse give the UAP?

Standard precautions are sufficient because the infection is transmitted sexually.

Which equipment should the nurse plan to have at the bedside when initiating a clear liquid diet in a postoperative client who has had general anesthesia?

Suction equipment

The nurse on a behavioral health unit is having a therapeutic discussion with a client and recognizes that which communication techniques would be nontherapeutic? Select all that apply.

3. Minimizing feelings 4. Changing the subject 5. Asking "why" questions

The nurse is caring for a neonate that is 3 hours old and should assess for which signs/symptoms of cold stress? Select all that apply.

3. Mottling of skin 5. Increased respirations with apnea

The nurse was assigned to care for five clients and spent most of the day caring for one of these clients who had just returned from surgery. The nurse did not ask for assistance and did not regularly check on the other clients. During the day, one of the nurse's other clients got out of bed without calling for assistance and fell, breaking his arm. Which possible charges could this nurse face with this situation? Select all that apply.

3. Negligence 4. Malpractice 5. Abandonment of care

The nurse is caring for a child with human immunodeficiency virus (HIV). It is most important that the nurse use which precautions to protect herself and her other clients from infection with HIV? Select all that apply.

3. Perform hand hygiene before and after contact with the client. 4. Use biohazard bags for items saturated with blood and bodily fluids. 5. Wear personal protective equipment when contact with blood and other bodily fluids are anticipated.

A client asks the nurse to describe the preferred provider organization model of care because the client is unsure of the procedure involved in this form of health care. Which statement by the nurse indicates an inaccurate description of this form of organization?

A client enters the ambulatory clinic, stating she has just been stung by a bee. Her vital signs are stable, and she has no previously known allergy to bee stings. The "stinger" is still visible in her arm. What should be the nurse's first action?

A licensed practical nurse (LPN) is asked to prepare an intravenous (IV) infusion of 1000 mL 5% dextrose in lactated Ringer's at 80 mL/hr to be administered to an assigned client. The LPN time-tapes the bag with a start time of 09:00. After making hourly marks on the time-tape, the LPN notes that which time would mark the completion time for the bag?

The nurse is completing a medication reconciliation form for a client. Which is a primary purpose of this process?

The nurse is reinforcing instructions to the unlicensed assistive personnel (UAP) who will be caring for a client with security devices (hand restraints). How often should the nurse instruct the UAP to check the client's skin and circulation under the security devices?

The nurse prepares the client for irrigation of an abdominal wound. Refer to video. Click on the Question Video button to view a video showing preparation procedures. After preparation, the nurse should appropriately don which article (s) to perform the procedure?

Which statement should the nurse include when providing safety instructions to the parents of an infant with a diagnosis of hydrocephalus?

A client is being discharged to home following spinal fusion with insertion of rods. For which home environment situation should the nurse suggest a consultation with the continuing care nurse?

The nurse is caring for a client with a diagnosis of end-stage renal disease. The client tells the nurse that a lawyer has prepared a living will and will be visiting the client today so that the will can be reviewed. The client also tells the nurse that the lawyer has asked for a witness to sign the will and requests that the nurse act as a witness. Which is the appropriate nursing response to the client?

"A nurse caring for a client cannot serve as a witness to a living will."

A nursing instructor asks a nursing student to describe accountability. Which statement by the student indicates an inaccurate description of accountability?

"Accountability can be delegated."

A pregnant woman has tested positive for human immunodeficiency virus (HIV). The nurse reinforces information to the client about HIV and determines that additional counseling is necessary when the client makes which statement?

"Breast-feeding after delivery is best for my baby."

A pregnant client tests positive for the hepatitis B virus (HBV), and the client asks the nurse whether she will be able to breast-feed the baby as planned after delivery. The nurse makes which response to the client?

"Breast-feeding is allowed once the baby has been vaccinated."

The nurse has reinforced the client instructions regarding crutch safety. Which comment by the client would indicate a need for further teaching?

"Crutch tips will not slip, even when wet."

A mother of a child brings the child to a clinic and reports that the child has a fever and has developed a rash on the neck and trunk. Roseola is diagnosed, and the mother is concerned that her other children will contract the disease. Which instruction should the nurse reinforce to the mother to prevent the transmission of the disease?

"Disease transmission is unknown."

A client is seen in the health care clinic, and a diagnosis of conjunctivitis is made. The nurse reinforces discharge instructions to the client regarding care of the disorder while at home. Which statement by the client indicates a need for further teaching?

"I do not need to be concerned about spreading this infection to others in my family."

The nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the child and the prevention of the transmission of the virus. Which statement by a parent indicates a need for further teaching?

"I need to provide a well-balanced, high-fat diet to my child."

The nurse educator determines that a newly hired licensed practical nurse (LPN) in a local hospital demonstrates an accurate understanding of professional liability insurance when which statement is made?

"I should obtain my own malpractice insurance."

The nurse reinforces home-care instructions to the parents of a 3-year-old child who has been hospitalized with hemophilia. Which statement by a parent indicates the need for further teaching?

"I will avoid immunizations and dental hygiene treatments for my child."

A halo vest is applied to a client following a cervical spine fracture. The nurse reinforces instructions to the client regarding safety measures related to the vest. Which statement by the client indicates a need for further teaching?

"I will bend at the waist, keeping the halo vest straight to pick up items."

A client brought to the emergency department is dead on arrival (DOA). The family of the client tells the health care provider that the client had terminal cancer. The emergency department health care provider examines the client and asks the nurse to contact the medical examiner regarding an autopsy. The family of the client tells the nurse that they do not want an autopsy performed. Which response to the family is appropriate?

"I will contact the medical examiner regarding your request."

The nurse is working in the primary care office and is conducting an interview with the parents of a child. The parents of the child state that syrup of ipecac is kept at home in case of an accidental poisoning. The nurse provides which appropriate instruction specific to the use of this medication?

"Ipecac syrup should not be given unless the poison control center indicates to do so."

The nurse asks a nursing student to describe case management. Which student response indicates a lack of understanding about this concept?

"It represents a primary health prevention focus managed by a single case manager."

A child is diagnosed with viral conjunctivitis and antibiotic eye drops are prescribed for the child. The mother asks the nurse when the child can return to school. The nurse should make which response to the mother?

"The child should be kept home until the antibiotic eye drops have been administered for 24 hours."

A child with leukemia is hospitalized and is receiving chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden and asks the nurse for a vase for the flowers. Which response by the nurse is appropriate?

"The flowers from your garden are beautiful, but they should not be placed in the child's room at this time."

A mother brings her child to the clinic because the child has developed a rash on the trunk and scalp. The child is diagnosed with varicella. What will the nurse tell the mother about the infectious period?

"The infectious period is 1 to 2 days before the onset of the rash to 5 days after the onset of lesions and the crusting of lesions."

Which statement by a pregnant client who is human immunodeficiency (HIV) positive indicates her understanding of the risk to her newborn during delivery?

"There is a risk of transmission from HIV-positive mothers to their newborn, although the newborn may be asymptomatic at birth."

A client with glaucoma has suffered significant eye damage before diagnosis and now has impaired vision. The nurse determines that the client needs further assistance in adapting to this situation if the client makes which statement?

"There is no difficulty driving at dusk."

The nurse reinforces home care instructions to the parents of a child hospitalized with pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement by the parents indicates a need for further teaching?

"We need to maintain respiratory precautions and a quiet environment for at least 2 weeks."

The nurse shares with a pregnant client that the result of her rubella screening is positive. Which is the nurse's response when asked by the client if it is safe for her 15-month-old toddler to receive the rubella vaccine?

"You are immune to the virus so it is safe for your toddler to receive the vaccine at this time."

A health care provider prescribes an intramuscular (IM) dose of 250,000 units of penicillin G benzathine (Bicillin). The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine 300,000 units/mL. How much medication will the nurse prepare to administer the correct dose? Fill in the blank. Record your answer to one decimal place.

0.8

A client who attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. The nurse, being most concerned with the client's safety, should take which action?

A client with active tuberculosis (TB) demonstrates less-than-expected interest in learning about the prescribed medication therapy. Which technique would the nurse ultimately need to employ in order to encourage participation?

The nurse is aware that the American's with Disabilities Act provides which rights to individuals who are disabled? Select all that apply.

1. 2. 4.

A client requiring upcoming surgery is extremely anxious about the need for a possible blood transfusion and is concerned about the risk of infection from contaminated blood. The nurse suggests that the client consider which as an effective method to minimize this risk?

A client who has had spinal fusion and insertion of hardware is extremely concerned about the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to work. The nurse understands that the client's needs should best be addressed by referral to which service?

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate?

An adult client is brought to the emergency department by ambulance after being hit by a car. The client is unconscious and is in shock. A perforated spleen is suspected, and emergency surgery is required immediately in order to save the client's life. No family members are present. In regard to informed consent for the surgical procedure, the nurse plans to take which best nursing action?

The client plans to give their lispro (Humalog) insulin injection at 0800 right before eating breakfast. The nurse knows that the client understood the education provided when the client states which time presents the greatest risk for hypoglycemia?

The nurse finds the client lying on the floor. The nurse calls the registered nurse, who checks the client and then calls the nursing supervisor and the health care provider to inform them of the occurrence. The nurse completes the incident report for which purpose?

The nurse is initiating seizure precautions for a child being admitted to the nursing unit. Which items are essential for the nurse to place at the bedside?

The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which measure should the nurse avoid in planning for the client's safety?

The nurse is preparing to apply a mitten restraint to the client's hand. The nurse does which to ensure that the restraint is applied correctly? Refer to video. Click on the Question Video button to view a video showing preparation procedures.

The nurse is preparing to initiate a tube feeding for a client, and the health care provider has prescribed the use of an electronic feeding pump. The nurse brings the pump to the bedside to plug the pump cord into the wall and discovers that there is no available outlet in the wall socket. Which action should the nurse implement?

The nurse is assigned to care for a client with a peripheral intravenous (IV) infusion. The nurse is providing hygiene care to the client and should avoid which while changing the client's hospital gown?

The nurse plans to admit a client who has seizure precautions prescribed. Which pieces of equipment should be available at the client's bedside in the hospital room? Select all that apply.

2. 5. 6.

A 1-year-old child is admitted to the hospital for control of tonic-clonic seizures. The nurse should perform which actions in order to protect the child from injury? Select all that apply.

2. Turn the client to the side during a seizure. 3. Keep side rails and other hard objects padded.

A client is brought to the emergency department by the ambulance team after collapse at home. Cardiopulmonary resuscitation is attempted but is unsuccessful. The wife of the client tells the nurse that the client is an organ donor and that his eyes are to be donated. Which action should the nurse take next?

A client with obsessive-compulsive disorder (OCD) who continually cleans the bathroom becomes enraged with the roommate for using the bar of bathing soap for cleaning the bathroom. The client begins to yell and slaps the roommate. Which action should the nurse take first?

A mother tells the pediatrician's office nurse that she is concerned because her children must let themselves into the house after school each day while she is at work. The nurse should explore with the mother which suggestion to decrease the children's sense of isolation and fear?

An explosion occurred at an industrial plant involving injury to 50 victims. The nurse at the scene determines that which victim should be transported to the hospital first?

The nurse is assigned to care for a child who is in skeletal traction. The nurse needs to avoid which action when caring for the child?

The nurse is reviewing the health care provider's prescriptions written for a client admitted with a diagnosis of acute cellulitis of the lower leg. The nurse should question which prescription?

The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions?

The nurse reinforces instructions regarding respiratory precautions to the mother of a child with mumps. The mother asks the nurse about the length of time required for the respiratory precautions. The nurse should base the response on which information about mumps?

The nurse working in the long-term care facility understands which concept related to depression in the older client?

When checking a client's skin, the nurse notes the presence of multiple straight and wavy threadlike lines beneath the skin and suspects the presence of scabies. Which precaution should the nurse institute before making contact with the client?

The nurse is reinforcing home care instructions to the mother of a child diagnosed with pneumonia. Which statement by the mother indicates the need for further teaching?

The nurse is caring for a client who has been diagnosed with a dissociative disorder. Which interventions should the nurse use in providing care for the client? Select all that apply.

3. 4. 5.

The nurse is educating a community group about risk factors for suicide and knows a member needs further teaching when which criteria are chosen as risk factors? Select all that apply.

3. 4. 5.

The nurse caring for a client who has been diagnosed with stage 3 Alzheimer's disease and should expect to observe which behaviors in this client? Select all that apply.

3. 5.

A client is transferred from the special care unit to the medical-surgical unit. The nurse receives report and plans to calculate the fall risk. The client is a male, aged 61, admitted to the hospital after being injured in a motor vehicle crash. He has no history of falling. He has no vision or hearing deficits. He has a peripheral continuous intravenous infusion, an indwelling urinary catheter, and sequential compression devices (SCD) while in bed. His gait is steady. He needs supervision when ambulating and uses the call light to contact the nurse for assistance. His prescribed medications include furosemide (Lasix), penicillin (Nafcillin) and ibuprofen (Motrin). He has received ibuprofen (Motrin) twice in the last 24 hours. He is oriented and cooperative. Which score should the client receive based on the fall risk tool? Refer to figure.

9 total points (moderate risk)

The nurse witnesses an accident on a highway and stops to provide assistance to the victim. The nurse notes that the client sustained a head injury and a compound fracture to the left leg. The nurse provides the appropriate care before transport of the victim to the hospital by ambulance. The client develops a severe bone infection at the site of the fracture that requires amputation of the leg and files suit against the nurse who provided care at the scene of the accident. Which is accurate regarding the nurse's immunity from this suit?

A Good Samaritan law will protect the nurse.

The nurse has received a 7 am change of shift report on four clients. Which client should the nurse check first?

A client admitted early this morning with right lower quadrant abdominal pain and an elevated leukocyte count

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse collect data on first?

A client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse collect data from first?

A client receiving oxygen who is having difficulty breathing

The nurse is planning the client assignments for the day. Which is an appropriate assignment for the unlicensed assistive personnel (UAP)?

A client who requires a 24-hour urine collection

The nurse is caring for a client with esophageal varices who is going to have a Sengstaken-Blakemore tube inserted. The nurse brings which priority item to the bedside so that it is available at all times?

A pair of scissors

Which is a recommended guideline for safe computerized charting?

Accidental deletions from the computerized file need to be reported to the nursing manager or supervisor.

The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the emergency department. Which should be the initial nursing action?

Activate the agency emergency response plan.

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. Which is the next nursing action?

Activate the fire alarm.

The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. The student correctly identifies which aspect of care as a priority of care?

Actual or life-threatening concerns

The nurse is reviewing the preoperative prescriptions of a client scheduled for a keratoplasty. Which prescriptions noted in the client's chart should the nurse question?

Administer medication to dilate the affected pupil.

The nurse is reviewing the plan of care developed by a nursing student for a client scheduled for keratoplasty. The nurse discusses the plan with the student if which incorrect intervention is listed in the plan?

Administering medications that will dilate the pupil

A client arrives at the emergency department and complains of severe abdominal pain. The initial diagnosis is acute abdomen, and an x-ray and an abdominal ultrasonogram are prescribed to be obtained immediately. The nurse prepares the client for these diagnostic tests and reviews the health care provider's prescriptions. Which prescription should the nurse question if written on the health care provider's prescription form?

Administration of an opioid analgesic

The nurse is told that a client will be admitted to the hospital for a radiation implant for bladder cancer. The nurse is asked to prepare for the admission of the client and plans which measure for this client?

Admit the client to a private room.

The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. Which is the next action the nurse should perform?

Aim at the base of the fire.

Following a tonsillectomy, which of the health care provider's prescriptions should the nurse question?

Allow ice cream when awake.

The nurse sees another nurse administer an incorrect medication to a client. The nurse who administered the incorrect medication does not report the error. Which would be the initial action by the nurse who observed the error?

Ask the nurse if he or she intends to report the error.

The nurse who works in a cardiac unit reports to work and is told that she needs to float to the neurological nursing unit because of a short-staffing problem on that unit. The nurse reports to the unit and receives a client assignment for the day from the nurse manager. The nurse is angry with the assignment because of a belief that the assignment is more difficult than the assignment delegated to other nurses on the unit. The nurse should carry out which action?

Ask the nurse manager of the neurological unit to discuss the assignment.

The nurse is assisting in planning client assignments. Which is the least appropriate assignment for the unlicensed assistive personnel (UAP)?

Assisting a profoundly developmentally disabled child to eat lunch

The nurse is caring for a client with glaucoma. Which medication prescribed for the client should the nurse question?

Atropine sulfate (Isopto Atropine)

A client experiences a cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style?

Autocratic

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I don't want help. I have other things to attend to that are more important." The nurse attempts to discuss the client's concerns, but the client dresses and begins to walk out of the hospital room. The nurse should take which action?

Call the nursing supervisor.

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle attached to a syringe containing a clear liquid into the antecubital area. Which action would be the appropriate initial action by the nurse?

Call the nursing supervisor.

The nurse is preparing an intravenous (IV) solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse should plan to take which action?

Change the IV tubing.

The nurse is caring for a client who is receiving an intermittent feeding via a nasogastric (NG) tube. Before feeding the client via the NG tube, the nurse should take which action?

Check the placement of the tube.

The nurse should plan which to encourage rebreak in the client who is a resident in a long-term care facility?

Choosing his social activities

The nurse reviews the health care provider's treatment plan for a client with Guillain-Barré syndrome. Which prescription noted in the client's record should the nurse question?

Clear liquid diet

The nurse is preparing to administer medications to an assigned client and notes that the prescription for furosemide (Lasix) is higher than the recommended dosage. The nurse calls the health care provider to clarify the prescription and asks the health care provider to prescribe a dosage within the recommended range. The health care provider refuses to change the prescription and instructs the nurse to administer the dose as prescribed. Which action should the nurse take?

Contact the nursing supervisor.

The nurse is giving the client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed to touch down the affected leg. How should the nurse teach the client to use the crutches?

Crutches and the left leg, then advance the right leg

The nurse in charge of a nursing unit in a long-term care facility is concerned because staff members openly verbalize racial comments about clients on the unit. What should the nurse do to appropriately manage this concern?

Discourage the racial comments.

A vascular surgeon repeatedly asks the nurse to obtain signed consent forms on his surgical clients. The nurse is uncomfortable with obtaining the informed consents and explains this to the surgeon, but the surgeon tells the nurse that she will be reported if the consents are not obtained. The nurse should appropriately manage this situation by taking which action?

Discuss the situation with the nurse manager.

A client is diagnosed with Haemophilus influenzae pneumonia. In addition to standard precautions, which other precautions should be instituted immediately by the nurse?

Droplet precautions

A client is receiving bolus feedings via a nasogastric tube. The nurse plans to place the client's head of the bed (HOB) in which optimal position once the feeding is completed?

Elevated 30 to 45 degrees with the client in the right lateral position for 60 minutes

An adolescent client is admitted to the hospital following an accidental gunshot wound to the foot. The nurse should plan to do which as a first step for the prevention of future injury?

Explore the adolescent's knowledge of gun safety.

The nurse provides instructions to the mother of a child with impetigo regarding the application of antibiotic ointment. The mother asks the nurse when the child can return to school. Which response by the nurse is appropriate?

Forty-eight hours after using the antibiotic ointment

The nurse is preparing to administer an enteral feeding through a nasogastric tube. The nurse should place the client in which position during and after the feedings?

Fowler's

Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?

Get a written prescription from the health care provider (HCP) and obtain an informed consent.

The nurse is caring for a client with a health care-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which protective items will be required to perform this procedure?

Gloves, a gown, and goggles

The nurse is assigned to care for a client on contact precautions. On review of the client's record, the nurse notes that the client has a hospital-acquired infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator and requires frequent suctioning. The nurse gathers supplies before entering the client's room and obtains which necessary protective items?

Gloves, mask, gown, and goggles

The nurse witnesses an automobile accident and provides care at the scene of the accident to an open wound on a young child. The family is extremely grateful and insists that the nurse accept monetary compensation for the care provided to the child. Because of the family's insistence, the nurse accepts the compensation to avoid offending the family. The child develops an infection and sepsis and is hospitalized. The family files suit against the nurse who provided care to the child at the scene of the accident. The nurse understands that which is accurate regarding immunity from this suit?

Good Samaritan laws will not provide immunity from suit if the nurse accepted compensation for the care provided.

A visitor brings a suicidal client a brightly packaged gift. The nurse accompanies the visitor to the client's room and takes which action?

Has the client open the gift with the nurse present

The nurse is reviewing the medication record of a client with acute gastritis. Which medication noted on the client's record should the nurse question?

Ibuprofen (Motrin)

The nurse is assisting in the preparation of a client for a blood transfusion. Which item is the most important for the completion of the identification process?

Identification bracelet

After attending the same social function 5 days ago, 50 individuals arrive at the hospital over a 4-day period with fever; an itchy, reddish brown papule; and complaints of nausea, vomiting, and severe abdominal pain. Cutaneous anthrax is suspected by the health care team. Which is the nurse's priority for client care?

Institute contact precautions.

Which instructions should be included in the teaching plan for a mother whose newborn is human immunodeficiency virus (HIV) positive?

Instruct the mother and family to provide meticulous skin care to the newborn and to change the newborn's diaper after each voiding or stool.

A child has been diagnosed with meningococcal meningitis. Which precautionary technique is appropriate to prevent transmission of the disease?

Isolation precautions for at least 24 hours after the initiation of antibiotics

A new nurse is employed at a local community hospital and is attending an orientation session. The nurse educator conducting the session asks the new nurse to describe an organization's mission statement. The new nurse appropriately responds with which statement?

It outlines what the organization plans to accomplish.

The nurse is reinforcing instructions to a client about safety measures while using oxygen in the home. The nurse determines that the client needs further teaching if the client verbalized which statement?

Keep the oxygen concentrator as close to the room wall as possible.

The nurse is assigned to assist with caring for a neonate born to a mother who is human immunodeficiency virus (HIV) positive. The nurse understands that which should be included in the plan of care?

Maintaining standard precautions at all times while caring for the neonate

A client has just undergone a gastroscopy. Which action should be taken by the nurse as the essential postprocedure nursing intervention?

Monitoring for the gag reflex

The nurse is reviewing a health care provider's prescriptions for a client with newly diagnosed, untreated hypothyroidism. Which medication prescribed for the client should the nurse question and verify?

Morphine sulfate

A client tells the nurse that he is feeling out of control. The nurse observes that the client is pacing back and forth. Which approach by the nurse is appropriate to maintain a safe environment?

Move the client to a quiet room and talk about his feelings.

Atropine sulfate is prescribed for a client with gastrointestinal hypermotility, and the nurse reviews the client's record before administering the medication. Which finding, if noted on the client's record, indicates the need to contact the health care provider before administering the medication?

Narrow-angle glaucoma

A client tells the nurse about deciding to refuse external cardiac massage. Which should be the most appropriate initial nursing action?

Notify the health care provider of the client's request.

The nurse is reviewing the record of a client who is hospitalized for treatment of a panic disorder. The nurse notes that the client was admitted by voluntary hospitalization. During the day, the client runs down the hallway and demands release from the hospital. The nurse notes that the client is exhibiting signs of anxiety and attempts to assist the client back to the client's hospital room. The next appropriate nursing action at this time is which?

Notify the registered nurse (RN).

The nurse is attending an agency orientation regarding the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. What does the nurse determine is a characteristic of this type of nursing model practice?

Nursing personnel are led by an RN leader in providing care to a group of clients.

The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which is a characteristic of this type of nursing model of practice?

Nursing staff are led by the nurse when providing care to a group of clients.

The nurse is preparing to change the neck ties on a tracheostomy tube. Which action should the nurse take?

Obtain a second health care team member to assist.

The nurse has a prescription to obtain a sample for urinalysis from a client with an indwelling urinary catheter. To prevent contamination of the specimen, the nurse should avoid which action?

Obtaining the specimen from the urinary drainage bag

The nurse working in a long-term care facility is approached by the son of a resident, who wants his 78-year-old father to have a heating pad because "his feet are always cold at night." The nurse should incorporate which concept when formulating a response to the family member?

Older adults often have slower neurological response times and are therefore more at risk for burns.

An automatic external defibrillator (AED) interprets that the rhythm of a pulseless client is ventricular fibrillation. The nurse takes which action next?

Orders personnel away from the client, charges the machine, and depresses the discharge buttons

A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The nurse reviews the plan of care and should question which intervention that is written in the plan of care?

Palpate the abdomen for a mass.

A bone marrow aspiration is scheduled for a client suspected of having leukemia. The nurse prepares supplies for the procedure and plans to bring which skin cleansing agent to the bedside before this procedure?

Povidone-iodine (Betadine)

The nurse is assigned to reinforce instructions to a client and the family about the management of home intravenous (IV) infusion therapy. The nurse begins the process by teaching the client and family principles related to what actions first?

Proper hand-washing technique

The nurse enters a laundry room to empty a bag of dirty linens and discovers that there is a fire in the laundry room. The nurse activates the alarm, closes the laundry room door, and obtains a fire extinguisher to extinguish the fire. Which is the first action when using the fire extinguisher?

Pulling the pin on the fire extinguisher

The nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which nursing action is the priority?

Removing the client from any immediate danger

A client who suffered a cervical spine injury had Crutchfield tongs applied in the emergency department. The nurse should avoid which action in the care of the client?

Removing the weights when repositioning the client

The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action?

Report to the pediatric unit and identify tasks that can be safely performed.

A child with rubeola (measles) is being admitted to the hospital. When preparing for the admission of the child, which precautions should be implemented?

Respiratory

A client with a diagnosis of tonic-clonic seizures is being admitted to the hospital, and the nurse needs to institute seizure precautions. During a seizure, which item is least appropriate to use and could cause harm to the client?

Restraints

The nurse is assisting in developing a plan of care for a child who will be returning from the operating room following a tonsillectomy. The nurse plans to place the child in which position on return from the operating room?

Side-lying

The nurse calls the health care provider (HCP) of a client scheduled for a cardiac catheterization because the client has numerous questions regarding the procedure and has requested to speak to the HCP. The HCP is very upset and arrives at the unit to visit the client after prompting by the nurse. The nurse is outside the client's room and hears the HCP tell the client in a derogatory manner that the nurse "doesn't know anything." The nurse plans to address the HCP's remark, understanding that the HCP has violated which legal tort?

Slander

Stay with the client at all times.

Taking photographs of the client without consent

The nurse in the psychiatric unit is reviewing the records of the clients admitted to the nursing unit. A client with a history of violent behavior approaches the nurse and demands immediate discharge from the hospital. The nurse notes that the client was voluntarily admitted to the psychiatric unit. Which is the appropriate nursing action?

Tell the client that the health care provider will be contacted regarding discharge.

The nurse is reviewing the record of a client admitted to the mental health unit and notes that the client was admitted by voluntary status. The nurse makes which determination?

The client has the right to demand and obtain release from the hospital.

The nurse has delegated care of a client with chronic obstructive pulmonary disease (COPD) to an unlicensed assistive personnel (UAP). The UAP notifies the nurse that the client's vital signs are elevated and the client is complaining of pain and dyspnea. Which is appropriate regarding the nurse's next action?

The nurse checks the client and gathers additional data before calling the health care provider.

After pleading for information, a visitor learns from the nurse that his friend (the client) has died from human immunodeficiency virus (HIV). Inadvertently, the visitor informs the client's family about the client's HIV diagnosis. Which is the most serious potential consequence of possible damages caused by these events?

The state convicts the nurse for invasion of privacy.

The nursing student and clinical instructor are performing tracheotomy suction at the bedside of an adult client with a tracheostomy. Which action by the nursing student is incorrect, causing the clinical instructor to intervene?

The student suctions the client's tracheotomy tube for 15 seconds.

The nurse is explaining the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery to a group of nursing students. Which action does site marking involve?

The surgeon marking the area of the operative procedure

The nurse is assisting in working with disaster relief following a tornado. The nurse's goal with the overall community is to prevent as much injury and death as possible from the uncontrollable event. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are examples of which type of prevention?

The tertiary level of prevention

The nurse is performing an environmental assessment in the home of an older client. Which requires immediate attention?

Unsecured scatter rugs

The nurse is planning to feed an older client who is at risk for aspiration of food. During the meal, how should the nurse position the client?

Upright in a chair

The nurse answers the call bell of a client who had insertion of an internal cervical radiation implant. The client states that the implant fell out, and the nurse sees it lying in the bed after moving back the sheet. Which action should the nurse take?

Use long-handled forceps to place the implant in a lead container.

A nursing student is planning care for a client with paraplegia who is at risk for injury because of spasticity of his leg muscles. The nurse intervenes if the student plans to include which intervention to minimize the risk of injury to the client?

Use of padded restraints to immobilize the limb

The nurse reviews the laboratory values on a child with leukemia receiving chemotherapy. The nurse notes that the platelet count is 19,000/mm3. Based on this laboratory result, which action should the nurse include in the plan of care?

Using a soft toothbrush for mouth care

The nurse is assigned to care for a client who has been diagnosed with human immunodeficiency virus (HIV). In planning care for the client, the nurse understands that educating staff concerning which instruction will have the greatest impact on minimizing the spread of the virus?

Using personal protective equipment appropriately

The nurse has reinforced instructions to a postpartum client who is hepatitis B positive how to safely bottle-feed her newborn to prevent the transmission of the infection. Which action by the client indicates an understanding of this procedure?

Washes and dries her hands before feeding

The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions should the nurse institute during the care of the client?

Wear a gown and gloves.

A furiously angry and aggressive client was put in restraints and was told that the restraints would be removed once the client regained control. The nurse appropriately removes the restraints when which action occurs?

When no acts of aggression are observed within 1 hour after release of two extremity restraints

The nurse is caring for a client in labor. The nurse notes the presence of fetal bradycardia on the fetal monitor and suspects that the umbilical cord is compressed. The nurse should immediately place the client in which position?

With the hips elevated

A client with glaucoma and an acute exacerbation of chronic obstructive pulmonary disease (COPD) has a new prescription to receive carteolol HCl (Ocupress) eye drops. Which action by the nurse is most appropriate?

Withhold the dose and notify the registered nurse.

A client with metastatic bladder cancer is admitted to the hospital for chemotherapy. During data collection, the client tells the nurse that a living will was prepared 2 years ago and asks the nurse if this document is still effective. Which is the most appropriate nursing response?

"A living will needs to be reviewed yearly with your health care provider."

The nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn. Which statement should the nurse make to the client?

"Hands should be washed thoroughly before holding the infant."

The nurse reinforces instructions regarding the use of permethrin 1% (Nix) to the parents of a child who has been diagnosed with pediculosis capitis (head lice). Which statement by a parent indicates the need for further teaching?

"The medication is applied to the hair after shampooing and left on for 24 hours."

A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which information to the client?

"You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed."

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. The appropriate nursing action is which?

A mother of a 6-year-old-child calls the nurse who lives in the neighborhood and tells the nurse that her child accidentally rubbed waterproof sunscreen in his eyes. Which should the nurse tell the mother to immediately perform?

The nurse knows that litigation involving nurses is common because of which reasons? Select all that apply.

1. Clients are better educated about health care. 2. Clients are better informed about their rights. 4. Clients have a higher expectation about the care they receive.

The nurse initiates a prescription from the health care provider and restrains a client who has a chest tube connected to suction. The client is confused and continues to remove the dressing around the tube and pulls at the tube. Which information should the nurse document in the client's medical record regarding restraints? Select all that apply.

3. Adequacy of circulation in the body area that is restrained 4. Type of restraint and body area where the restraint was applied 5. Communication with client and family member about need for restraint 6. The alternative measures that were attempted before restraints were applied

The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse should plan to tell the client to place the crutches in which position?

8 inches to the front and side of the client's toes

The nurse is caring for a client who is receiving intramuscular antibiotics. The nurse enters the client's room to administer the prescribed antibiotic, and the client tells the nurse that the medication burns and that he does not want the medication to be given. The nurse tells the client that the medication is necessary and administers the medication. With which crime can the client legally charge the nurse as a result of the nursing action?

Battery

Which car safety device should be used for a child who is 8 years old and is 4 feet tall?

Booster seat

A client who was struck by a car while jogging is brought to the emergency department by the ambulance team. The client is unconscious, and a ruptured spleen is suspected. Emergency measures are instituted but are unsuccessful. The client's fiancée is with the client and tells the nurse that the client is an organ donor. In anticipation that the client's eyes will be donated, which should the nurse implement?

Close the deceased client's eyes and place a small ice pack on the eyes.

The nurse is assigned to care for a newly admitted client and is reviewing the health care provider's prescriptions. The nurse notes that the health care provider has prescribed a medication dose that is twice the amount that the client reports taking before admission. Which nursing action is appropriate?

Consult with the registered nurse (RN).

The nurse is giving a bed bath to an assigned client. An unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. The nurse should do which?

Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

The nurse has reinforced instructions to a client with tuberculosis about proper handling and disposal of respiratory secretions. The nurse determines that the client understands the instructions if the client verbalizes to take which measure?

Discard used tissues in a plastic bag.

A student nurse has received the client assignment for the day and is organizing the required tasks. The nursing instructor reviews the plan for time management with the student and determines that the student needs assistance with the plan if the student indicated that which activity should be part of it?

Documenting task completion at the end of the day

The nurse is assisting in caring for a victim of a burn injury during the emergent/resuscitative phase. On data collection of the client the nurse notes that the urine output has decreased and the blood pressure is dropping. The nurse should perform which immediate action?

Notify the registered nurse.

An emergency department nurse is caring for an older client who may have been physically abused by her son. In planning care for the client, which is the priority nursing action?

Notify the social worker to investigate the situation.

A mother arrives at the emergency department with her child and a diagnosis of epiglottitis is documented. Which of the health care provider's prescription should the nurse question?

Obtain a throat culture.

Emergency surgery is scheduled for a client with a bowel obstruction. The licensed practical nurse (LPN) tells the registered nurse (RN) that she is unable to obtain informed consent from the client because the client has received opioid analgesics and is sedated. The LPN understands that which action should be implemented?

Obtaining a telephone consent from the family member and ensuring that the oral consent is witnessed by two persons

An older client is at risk for falls. When developing an individualized plan of care for this client, the nurse recalls that which concept is least relevant to maintenance of balance for the older client?

Older clients cannot think quickly enough to respond to emergencies.

The nurse is assisting in caring for a client with a head injury who is restless and is pulling at the intravenous (IV) line. The client's health care provider does not want to sedate the client, and the family has requested that the client not be restrained. The nurse should implement which?

Stay with the client and consult with the nurse manager about the situation.

Which nursing approach is important when administering an antianxiety agent to a client with acute severe anxiety?

Stay with the client until the medication becomes effective.

The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item?

Sterile 2 × 2 gauze

Following a cleft lip repair, the nurse reinforces instructions to the parents regarding cleaning of the lip repair site. Which solution should the nurse use in demonstrating this procedure to the parents?

Sterile water

The nurse is assisting in conducting a group therapy session. During the session a client threatens to act out physically and states that he will punch another member of the group. Which is the appropriate nursing action?

Tell the client that he may talk about his anger but cannot act on it during the group session.

The nurse is caring for a client with severe cardiac disease. While the nurse is caring for the client, the client states, "If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me." Which is the appropriate nursing action?

Tell the client that it is necessary to notify the health care provider of the client's request.

Which should be included in the plan of care for a pregnant teenager to reinforce instructions regarding dental care?

Tell the dental office staff that she is pregnant.

The nurse witnesses an accident in which the victim was hit by a car. The nurse stops at the scene of the accident and administers safe care to a victim who sustained a compound fracture of the femur. The victim is hospitalized and later develops sepsis as a result of the fractured femur. The victim files suit against the nurse who provided care at the scene of the accident. Which accurately describes the nurse's immunity from this suit?

The Good Samaritan laws will protect the nurse if the care given at the scene was not negligent.

Which identifies the route of transmission of tuberculosis (TB)?

The airborne route

A client who had a lung resection for cancer has been told that bone metastasis has occurred. The client is considering megavitamin and diet therapy because the original surgery did not provide a cure. The client asks the nurse for an opinion of these therapies. In formulating a response, the nurse incorporates which concepts?

The client's right to autonomy and the nurse's obligation to behave ethically

An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action?

Transport the client to the operating department immediately, as required by the health care provider, without obtaining an informed consent.

A client has been prescribed cyclobenzaprine (Flexeril) in the treatment of painful muscle spasms accompanying a herniated intervertebral disk. The nurse should withhold the medication and question the prescription if the client had which concurrent prescriptions to take?

Tranylcypromine (Parnate)

A client with tuberculosis (TB) who is being prepared for discharge to home should be instructed to follow which practice to decrease the possibility of spreading the infection?

Wear a mask when in contact with people outside of the family until medications are effective.

Which guidelines should the nurse follow when performing narrative documentation? Select all that apply.

1. 2. 3. 5.

The nurse administers erythromycin ointment (0.5%) to the newborn's eyes, and the mother asks the nurse why this is done. The nurse should give which response to the client?

Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection

The nurse should institute which type of precaution for a client diagnosed with Clostridium difficile?

A client with Parkinson's disease "freezes" while ambulating, increasing the risk for falls. Which suggestion should the nurse include in the client's plan of care to alleviate this problem?

The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? Select all that apply.

4. 5. 6.

The nurse is documenting information regarding a client's care into the computerized medical record. Which actions by the nurse would be most effective in ensuring client confidentiality? Select all that apply.

1. Change the password for entering computer files at least monthly. 2. Shred the printout of the nurse's flowchart at the end of the nurse's shift. 3. Use own user name and password when logging into the computer system.

A client with a headache arrives in the emergency department and is staggering, confused, smells of alcohol, and is verbally abusive. The nurse explains to the client that the health care provider will need to perform an assessment before the administration of medication. When the client becomes verbally abusive, the nurse threatens to place the client in restraints. With what can the client legally charge the nurse as a result of this nursing action?

Prescriptive eyeglasses are prescribed for a client with bilateral aphakia. When reinforcing teaching instructions regarding the eyeglasses, the nurse determines the need for further teaching when the client makes which statement?

The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response?

The nurse is caring for a client in the acute manic stage of bipolar disorder and plans to use which interventions to assist in maintaining a safe environment? Select all that apply.

1. 2. 3

When reinforcing instructions to an oriented client and the client's family regarding how to use the patient controlled analgesia (PCA) pump with both a basal and demand dose, the nurse should include which instructions? Select all that apply.

1. 2. 3. 5.

The nurse is caring for a client who is hospitalized because of severe depression. Which statements would be most helpful in assisting this client? Select all that apply.

1. 2. 4.

The nurse is aware that criminal offenses would have which characteristics as opposed to civil offenses? Select all that apply.

1. 2. 4. 5.

The nurse performs an audit in the hospital intensive care unit of clients who have indwelling urinary catheters. Which observation, found in the audit, poses a risk for a health care-associated infection? Select all that apply.

1. 2. 5.

Which home care instructions should the nurse plan to reinforce to the mother of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply.

1. 2. 5.

The nurse is caring for a client who has refused to take an oral medication. The nurse tells the client that the nurse will hold the client down and give the medication by injection if the client doesn't take the oral medication. The nurse then takes the client's bathrobe so the client will have to remain in his room. Which intentional torts has this nurse committed? Select all that apply.

1. 3.

The nurse is caring for a 4-month-old infant with respiratory syncytial virus (RSV). Several clients are being admitted to the unit and assignments are being made. The nurse should question being assigned which newly admitted clients? Select all that apply.

1. 4.

The nurse is caring for a client who becomes agitated and begins to pull on a surgically placed abdominal drainage tube. The health care provider visits and prescribes restraints if needed. Which action is appropriate to delegate to the unlicensed assistive personnel (UAP), who has completed the facility's education about care of the restrained client? Select all that apply.

1. 4. 5.

The nurse is planning the client assignments for the day. The assignment that the nurse communicates to the unlicensed assistive personnel (UAP) includes which clients? Select all that apply.

1. 4. 5.

A group of nurses are reinforcing instructions on health and safety management to survivors of a hurricane before they leave their temporary shelter and return home. Which instructions should the nurses include? Select all that apply.

1. Boil water for 5 to 10 minutes before drinking. 2. Wash hands with soap and water frequently. 3. Avoid mixing chemicals such as cleaning chemicals. 5. Add 10 to 20 drops of chlorine bleach to a gallon of water before drinking.

The nurse is caring for a client who just returned from surgery for repair of a fractured arm. The client complains of severe pain in the arm and also that his hand is feeling numb. The nurse notes that the client's fingers are pale and that the pulse in his arm is very weak. The nurse attempts to contact the surgeon numerous times, but the surgeon does not return the call. Who should the nurse notify at this time? Select all that apply.

1. Charge nurse 2. Hospital supervisor 4. Surgeon's supervisor

Place in correct order the steps the nurse should use to resolve an ethical dilemma. Arrange the actions in the order that they should be performed. All options must be used.

1. Determine if an ethical dilemma exists 2. Gather necessary information. 3. Clarify values. 4. Verbalize the problem. 5. Identify possible courses of action. 6. Negotiate a plan. 7. Evaluate the plan.

The nurse is preparing to bathe a client who has mild Alzheimer's dementia and requires minimal help with hygiene. Which is the priority order of nursing interventions? Arrange the actions in the order that they should be performed. All options must be used.

1. Develop a therapeutic relationship with the client. 2. Allow the client to select the type of bath. 3. Address privacy by closing the door and pulling the curtains around the bed. 4. Provide a back massage for relaxation. 5. Document interventions and the client's response.

The nurse is assisting in developing a plan of action for the emergency department in the event of an internal fire. Which should the nurse include in the plan? Select all that apply.

1. Direct ambulating clients to walk to a safe location. 4. Remove all clients from danger before attempting to extinguish the fire. 5. Move bedridden clients away from the fire area by use of beds or stretchers.

The nurse knows when preparing the Filipino American client for a surgical procedure it is important to assess for which culturally relevant influences? Select all that apply.

1. Familial hierarchy 2. Cultural practices 3. Reactions to surgery 4. Pain management plans

The nurse is aware that the ethical philosophy of deontology is composed of which "right-making characteristics"? Select all that apply.

1. Justice 3. Truthfulness 5. Fidelity to promises

The nurse is caring for an older adult and knows that an ethical dilemma is most likely to occur in this population because of which issues? Select all that apply.

1. Limited vision 2. Chronic illness 5. Lack of assertiveness

The nurse will perform a sterile dressing change after removing the old dressing with clean gloves. The nurse removes the gloves, uses alcohol-based hand sanitizer to perform hand hygiene, and prepares to perform open sterile gloving. The nurse removes the gloves from the outer package. The nurse is right-handed. Arrange the steps the nurse should follow in the open sterile gloving process. All options must be used.

1. Open inner wrapper and flatten wrapper to expose the gloves. 2. Pick up right glove at cuff with left thumb and forefinger. 3. Insert right hand into right glove. 4. Place gloved right hand under the cuff of left glove. 5. Insert left hand into left glove. 6. Pull down cuffs of gloves maintaining sterility.

A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply.

1. Pad the bed's side rails. 2. Place an airway at the bedside. 3.Place oxygen equipment at the bedside. 4. Place suction equipment at the bedside.

The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which data specifically associated with this therapy before the initiation of therapy? Select all that apply.

1. Pedal pulses 2. Capillary refill 3. Color of the extremity 4. Temperature of the skin

The nurse is caring for a client who has a wound infection. Contact precautions are being followed. Which are correct actions by the nurse when using personal protective equipment (PPE)? Select all that apply.

1. Perform hand hygiene after removal of PPE. 2. Perform hand hygiene before donning any PPE. 3. When removing PPE, always remove gloves first. 6. Protective eyewear and face shield are indicated if there is risk of splatter.

The nurse is caring for a homebound older postoperative cardiovascular client. The caregiver's daughter says to the nurse, "My mother has fallen out of bed three times." Which actions should the nurse reinforce to prevent falls? Select all that apply.

1. Provide adequate lighting. 3. Ensure that frequently used items are easily accessible. 4. Have the bedside stand and overbed tray table within reach.

The nurse is caring for a client in the acute manic stage of bipolar disorder and plans to use which interventions to assist in maintaining a safe environment? Select all that apply.

1. Provide high-calorie finger foods. 2. Decrease the light and noise level on the unit. 3. Restrict the client's access to money and other valuables.

The licensed practical nurse (LPN) is assisting in the admission of a child with suspected sickle cell crisis because of which signs/symptoms noted in this client? Select all that apply.

1. Swollen knee joint 3. Pulse,120 beats per minute 4. Peripheral oxygen level of 89% 5. Pain rated as a 6 on a scale of 1 to 10

The nurse is reinforcing instructions regarding the prevention of Lyme disease to a group of teenagers going on a hike in a wooded area. Which points should the nurse include in the session? Select all that apply.

1. Tuck pant legs into socks. 2. Wear closed shoes when hiking. 3. Apply insect repellent containing DEET. 4. Cover the ground with a blanket when sitting.

Which interventions would apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply.

1. Use nonlatex gloves. 2. Use medications from glass ampules. 4. Do not puncture rubber stoppers with needles. 5. Keep a latex-safe supply cart available in the client's area.

The nurse is attempting to ensure the parent is able to safely administer at home the prescribed ear drops to the 2-year-old client. The parent demonstrates understanding of the teaching by listing the steps of the process in which priority order? Arrange the actions in the order that they should be performed. All options must be used.

1. Warm the bottle of ear drops by rolling it in the palms of the hands to help decrease discomfort. 2.Have the child lie on his or her back with the affected ear facing up. 3. Straighten the ear canal by pulling the pinna of the affected ear down and back. 4. Slowly instill the number of drops prescribed by the health care provider into the ear. 5. Massage the area anterior to the ear to facilitate entry of the drops. 6. Keep the child in the same position for 2 to 3 minutes.

The nurse has received a client assignment for the day. In which priority order should the nurse see the clients? Arrange the clients in the order that they should be seen. All options must be used.

1.The 4-year-old client with heart failure (HF) who had to increase the elevation of the head of the bed to sleep because of dyspnea 2. The 2-year-old client receiving digoxin (Lanoxin) with a heart rate of 70 beats per minute 3. The 9-year-old client with rheumatic fever complaining of increased pain at a level of 8/10 4. The 15-year-old client scheduled for surgery in 2 hours who still needs preoperative teaching

The nurse administers an injection to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). After administering the medication, the nurse should dispose of the used needle by which method?

The nurse is taking care of a client preoperatively. The client is NPO and tells the nurse that he takes detemir insulin (Levemir) and aspart insulin (NovoLog) at 0700 daily. The client's surgery is scheduled for 0900. Which is the best action for the nurse to take?

The nurse is aware that which criteria are necessary for a situation to be classified as malpractice? Select all that apply.

2. 3. 4. 5.

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply.

2. "Mass casualty events do not require an increase in the number of staff that are needed." 3. "A mass casualty event occurs only within the heath care facility and could endanger staff." 4. "A mass casualty event occurs if a fight between visitors occurs in the emergency department."

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply.

2. "Mass casualty events do not require an increase in the number of staff that are needed." 3. "A mass casualty event occurs only within the heath care facility and could endanger staff." 5. "A mass casualty event occurs if a fight between visitors occurs in the emergency department."

A licensed practical nurse (LPN) is administering medications to a client with chronic rheumatoid arthritis. The client has difficulty swallowing, and the film-coated form of diflunisal is prescribed. Which action by the LPN is most appropriate?

A client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses the client 15 minutes after administering the medication and reminds the client to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Which issues support the client's malpractice claim? Select all that apply.

2. Increased risk of hypotension 3. Failure to teach the client adequately 4. Increased need to protect the client 6. Lack of follow-up nursing actions

The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which should the nurse include in the preparations? Select all that apply.

2. Open the distal flap of a sterile package first. 3. Prepare the sterile field just before the planned procedure. 6. Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field.

A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions should the nurse initiate? Select all that apply.

2. Place the child on a low-bacteria diet. 3. Change dressings using sterile technique. 5. Perform meticulous hand washing before caring for the child.

The nurse is performing oral care for a newly admitted client who is undergoing chemotherapy for thyroid cancer. The nurse should take which actions while performing oral care? Select all that apply.

2. Provide a soft toothbrush. 3. Check oral mucous membranes. 4. Check for missing teeth and cavities.

The critical care nurse is caring for a client with a subclavian central line catheter. The nurse knows that a specific central-line bundle was developed to reduce the client's risk for developing a catheter-related bloodstream infection (CLABSI). The interventions include which essential actions? Select all that apply.

2. Strict hand washing 4. Optimal catheter site selection 5. Strict sterile technique with maximal barrier precautions during placement

The licensed practical nurse is assisting the registered nurse (RN) in the care of a child who is receiving a blood transfusion and notifies the RN if the child displays which signs/symptoms of fluid overload? Select all that apply.

4. 5.

The health care provider writes a prescription for the nurse to obtain a consent for a colonoscopy. Which are the nurse's responsibilities to obtain an informed consent? Select all that apply.

2. To ensure the client is the age of consent 3. To ensure the client is signing voluntarily

Which are the most important interventions that can help reduce the incidence of hospital-acquired urinary catheter infections? Select all that apply.

2. Use indwelling urinary catheters judiciously. 3. Remove indwelling catheters when no longer needed. 4. Use strict aseptic technique when inserting all urinary catheters.

A client with tuberculosis (TB) who is being prepared for discharge to home should be instructed to follow which practice to decrease the possibility of spreading the infection?

The nurse is assisting in admitting a client who experienced seizure activity in the emergency department. The nurse avoids which action when managing this client's environment?

The nurse is caring for a client after a Billroth II (gastrojejunostomy) procedure. On review of the postoperative prescriptions, which should the nurse clarify?

The nurse is caring for a group of clients who are taking herbal medications at home. Which client should be given instructions in regard to avoiding the use of herbal medications?

The nurse is reinforcing home care instructions to the mother of a child with bacterial conjunctivitis. Which instruction should the nurse give the mother?

The nurse is reinforcing home care instructions to the mother of a child with hemophilia. Which activity should the nurse suggest that the child can safely participate in with peers?

A 9-year-old child with leukemia is in remission and has returned to school. The school secretary calls the mother of the child and tells the mother that a classmate has just been diagnosed with varicella (chickenpox). The mother immediately calls the nurse at the health care provider's office because the leukemic child has never had chickenpox. The nurse should make which response to the mother?

3. 4. 5.

3. 4. 5. 6.

The nurse is reinforcing instructions to a client regarding the use of ice packs to treat an eye injury. The nurse instructs the client to do which action?

Wrap a plastic bag filled with ice with a pillowcase and place it on the eye.

The nurse is assigned to the care of a client with an unsealed internal radiation source. During an 8-hour shift, the nurse plans the care to avoid spending more than how much time in the client's room?

30 minutes

A client with chronic obstructive pulmonary disease (COPD) asks the nurse for assistance with preparing a living will. The client tells the nurse that she has not discussed the living will with the family and wanted to make some decisions before discussing the will with the family. Which initial step in preparing this document should the nurse inform the client to do?

A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which response to the client is appropriate?

A nursing student is preparing to conduct a clinical conference, and the topic is hepatitis in children. The nursing instructor advises the student to further research the topic if the student plans to include which information in the discussion?

A pediatric nurse arrives at work and is told to report (float) to the emergency department (ED) for the day because the ED is expecting numerous victims to arrive following a train crash. The nurse has never worked in the ED and is anxious about floating to this area. Which is the appropriate nursing action?

The client diagnosed with paranoid schizophrenia has been exceedingly agitated, is threatening and shouting at everyone, and is refusing to participate in therapy. The nurse takes which initial action?

The nurse assists to conduct a home safety assessment with a client preparing for discharge, and the client tells the nurse that a space heater is used to heat the apartment. Which instruction should the nurse provide to the client regarding the use of the space heater?

The unlicensed assistive personnel (UAP) who has been employed in a long-term care facility for 8 weeks is consistently 10 to 20 minutes late for work. The UAPs lateness has caused unrest with other staff members in the nursing unit. The UAP is due to receive a 3-month probation evaluation in 1 month. Which is the most appropriate action by the nurse in charge of the nursing unit when dealing with this situation?

A client was involuntarily admitted to the psychiatric unit because of episodes of extremely violent behavior. The client is demanding to be discharged from the hospital. The licensed practical nurse (LPN) reports the information to the registered nurse (RN), and the RN does not allow the client to leave. The LPN understands that which represents the legal ramifications associated with the RN's behavior?

A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse should encourage the client to attend which community group?

A client is being transferred to the nursing unit from the postanesthesia care unit following spinal fusion with rod insertion. How should the nurse transfer the client from the stretcher to the bed?

A slider board and the assistance of four people

The nurse is caring for a client who is scheduled for electroconvulsive therapy (ECT). The nurse notes that an informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the admission was an involuntary hospitalization. Based on this information, which determination does the nurse make regarding consent?

An informed consent needs to be obtained from the client.

The nurse receives a telephone call from a neighbor who states that her child was found sitting on the floor near the kitchen sink playing with several bottles of cleaning fluids. The bottles of cleaning fluid were opened and spilled on the child and the floor, and the mother suspects that the child may have consumed some of the cleaning fluid. Which action should the nurse tell the mother to do immediately?

Call the area poison control center.

When assisting in the identification process required before a blood transfusion, which action will the nurse take when it is noted that all of the necessary information is correct, except for the client's name?

Call the blood bank about the discrepancy.

The nurse is working in a long-term care facility and is observing a new unlicensed assistive personnel (UAP) caring for a client who requires a security device (wrist restraints). The nurse determines that the nursing assistant is providing safe care if the nurse observes the UAP checking skin integrity by completely removing the client's wrist restraints at which time interval?

Every 2 hours

A preschool child who was admitted to the hospital for a minor surgery develops a rash on the second day after hospitalization and is diagnosed with chicken pox (varicella). The nurse should take which action to provide safety for all children on the unit?

Place the infected child and any immunocompromised children in isolation.

The nurse is assisting in developing a plan of care for a client receiving warfarin sodium (Coumadin). The nurse selects which problem as the priority in caring for this client?

Potential for injury

The nurse suspects that a co-worker is substance impaired and is self-administering opioid medications rather than administering them to clients as prescribed. Which action should the nurse take?

Report the information to a supervisor.

The nurse is instructed to complete a medication reconciliation form on a newly admitted client. Why is it important for the nurse to ensure that this process is completed accurately?

It helps to make sure that the health care provider is aware of all of the medications the client is taking and has been taking at home.

The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of the tasks?

Perform follow-up with each staff member regarding the performance and outcome of the task.

The nurse observes that a client received pain medication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed this same occurrence. Based on the nurse practice act, the observing nurse should plan to take which action?

Report the information to a nursing supervisor.

The nurse is speaking with a client with a hearing impairment. The nurse refrains from doing which least likely helpful action when communicating with this client?

Using many exaggerated hand gestures while talking

A client newly diagnosed with gout has been prescribed allopurinol (Zyloprim). The nurse should question the health care provider if the dose for which medication already prescribed has not changed?

Warfarin sodium (Coumadin)

The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made?

"I will drive only during the daytime."

The nurse is preparing to comb the hair of a client who has been treated for pediculosis. The nurse should perform the actions in which priority order? Arrange the actions in the order that they should be performed. All options must be used.

1. Apply disposable gown and gloves 2. Divide the client's hair in sections. 3. Look through the hair for nits still attached to the shaft of hair. 4. Remove nits with a fine toothed comb. 5. Soak the comb used in boiling water for 10 minutes.

The nurse on the day shift is assigned to care for the following six clients. List in order of priority how the nurse should plan to check the assigned clients. Arrange the actions in the order that they should be performed. All options must be used.

1. Client who has a tracheostomy and is on a mechanical ventilator 2. Client who requires before-breakfast insulin 3. Client who is scheduled for a cardiac catheterization at 9:00 am 4. Client who requires medications at 10:00 am 5. Client who has been diagnosed with diabetes mellitus and who is scheduled for discharge to home 6. Client who is scheduled for physical therapy in the afternoon

The nurse is reviewing the laboratory results of a client receiving chemotherapy. The nurse prepares to initiate neutropenic precautions when the nurse notes which laboratory result?

A white blood cell (WBC) count of 2000 cells/mm3

The nurse is assisting in preparing a client for a cardiac catheterization. The nurse understands that it is important to check the client's record for which history?

Allergy to shellfish

The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster?

An unlicensed assistive personnel who has never had chickenpox

The nurse is caring for a client at risk for postpartum endometritis. Which nursing intervention would minimize this risk following delivery?

Reviewing hand-washing techniques and pericare with the client

A client experiencing delusions of being poisoned is admitted to the hospital after not eating or drinking for several days. On data collection, the nurse notes no evidence of dehydration and malnutrition at this time. The nurse should immediately plan to address the client's need for which?

Safety and security

The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula. To provide a safe delivery of the oxygen the nurse should avoid which action?

Secures the oxygen tubing to the client's bottom sheet

The nurse overhears a client ask the health care provider if the results of a biopsy indicated cancer. The health care provider tells the client that the results have not returned, when in fact, the health care provider is aware that the results of the biopsy indicated the presence of malignancy. The nurse is upset that the health care provider has not shared the results with the client and tells another nurse that the health care provider has lied to the client and that this health care provider probably lies to all of the clients. Which legal tort has the nurse violated by this statement?

Slander

The client presents to the pediatrician's office with a temperature of 103° F for the past 3 days. The nurse also observes conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes. Using situation, background, assessment, and recommendation (SBAR communication), which statements and/or questions should the nurse use in communication with the health care provider regarding this client's condition? Select all that apply.

1. "I am concerned this client has Kawasaki's disease. Can you please come assess this client?" 2. "This client is a 4-year-old male who presented to the clinic with a temperature of 103° F for the past 3 days." 4. "I think this client is at risk for aneurysm and thrombi development and should be taken to the hospital immediately." 5. "I observed this client to have conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes."

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse knows that neutropenic precautions will be implemented if the client has which white blood cell (WBC) count?

2000 cells/mm3

The nurse is assisting in caring for a client receiving chemotherapy. On review of the morning laboratory results, the nurse notes that the white blood cell count is extremely low, and the client is immediately placed on neutropenic precautions. The client's breakfast tray arrives, and the nurse inspects the meal and prepares to bring the tray into the client's room. Which action should the nurse take before bringing the meal to the client?

Remove the fresh orange from the breakfast tray.

Following an airplane crash that had only a few survivors, the nurse should anticipate which survivor responses to stress? Select all that apply.

1. Difficulty sleeping 2. Feeling vulnerable 3. Feeling blame or guilt 4. Feeling numb or in disbelief

The nurse has just been licensed and has begun to practice in an acute health care facility. The nurse knows that which nursing specialties will require more specific defined standards of care and skills? Select all that apply.

1. Nurse-midwives 2. Nurse-anesthetists 3. Intensive care unit (ICU) nurses

The nurse is caring for a child with a platelet disorder and should expect which prescriptions from the health care provider? Select all that apply.

1. Observe for bleeding. 2. Encourage the child to rest. 5. Assist the registered nurse (RN) with blood transfusions.

The nurse is reviewing a health care provider's prescription for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? Select all that apply.

1. Restrict fluid intake. 6. Administer meperidine (Demerol) 25 mg for pain.

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