Safety Qbank

wheezes may indicate

-COPD -allergic reaction

risk for hospital acquired infection

-advanced age, malnutrition, immunocompromised

wound culture order

-assess pain level before procedure (incase need to medicate) -wash hands and use sterile gloves -clean exudate -insert sterile q tip into wound and rotate -crush ampulee and make sure covering all of medium

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

-determine if someone else is available to provide care -first see if can avoid exposure all together if CANT then go to reduction exposure risk

The home care nurse visits the young adult with a diagnosis of hepatitis A. Which statement, if made by the client to the nurse, indicates that further teaching is needed? "I have been very careful to wash my hands after I go to the bathroom." "I have had to take acetaminophen several times this week for this sinus infection I have." "I have been very careful not to handle my child's toys or eating utensils." "My spouse has been preparing all of the meals since I have been sick."

-i have had to take acetaminophen for sinus infection -should always avoid contact w/ things that other people will put in their mouths -liver may not be able to detoxify

A client diagnosed with a necrotizing spider bite is to perform dressing changes at home. The nurse determines which statement, if made by the client, indicates a correct understanding of aseptic technique? "I need to buy sterile gloves to redress this wound." "I should wash my hands before redressing my wound." "I should keep the wound covered at all times." "I should use an over-the-counter antimicrobial ointment."

-i should wash hands before redressing my wound

Menegitis sx (children/adolescents)

-nuchal rigidity -decreased LOC -photophobia -seizures -vomitting -+ kernig and brudzinski sign

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

-place an identification bracelet on each child priority is to identify children to aid in communication of rescue NURSE NEVER LEAVE CHILDREN ALONE

The nurse cares for a client with an internal radium implant. It is MOST important for the nurse to take which of the following actions? Restrict visitors with upper respiratory infections. Assign the client to male caregivers. Plan nursing activities to decrease time spent in the client's room. Wear a lead-lined apron when caring for the client.

-plan nursing activities to decrease time spent in clients room (max of 30 min per shift)

surgical hand scrub order

-remove all jewlery -turn on water w/ foot -use pick to clean under nails -scrub for 3-5 minutes -rinse hand and elbows w/ hands above elbows

process of urinary cath insertion

-wash hands -position and drape pt -sterile gloves -cleanse urinary meatus -insert catheter -fill balloon w/ sterile water (position "dirty pt" before putting on sterile gloves

can you suction a pt while seizing?

YES

can you leave door open in droplet precaution

Yes

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

a cat is sleeping on the windowsill r/t toxoplasmosis

The nurse cares for clients in the outpatient clinic during an outbreak of the flu. The nurse notes many family members accompanied clients to the clinic. Several of the family members appear to have a dry cough and runny noses. Which of the following actions should the nurse take FIRST? Inform the family members they should stay home if they have a cough. Instruct the coughing family members to sit at least 3 feet way from others. Post an alert at the entrance to the facility. Provide tissues to the family members.

THINK ALREADY THERE (HOW TO STOP SPREAD OF INFECTION THERE) -instruct coughing pt to sit 3 ft away from others

hantavirus pulmonary syndrome

severe respiratory disease -can be fatal -spread by rats -assess for thrombocytopenia: hematuria, bleeding gums, melena, hemataemesis may cause cardiopulmonary disease

The nurse observes staff caring for clients on the medical/surgical unit. The nurse determines care is appropriate when which observation is made? 1.The LPN/LVN cares for a client with a stage 1 pressure ulcer by wearing gloves. 2.The nursing assistive personnel (NAP) wears gloves while ambulating a client with an indwelling urinary catheter. 3.A registered nurse wears clean, non-sterile gloves when removing a Foley catheter. 4.A nursing assistive personnel (NAP) caring for a client on droplet precautions removes the mask prior to removing the gloves.

3. registered nurse wear clean nonsterile gloves when removing a foley

The nurse returns to a senior center to evaluate the effectiveness of a presentation about how to prevent falls among seniors. The nurse determines that teaching was effective if which responses are stated by the seniors? Select all that apply. "I started taking tai chi classes." "I have a new pair of athletic shoes with deep treads." "I went to the eye doctor to have my vision checked." "My physician reviewed all of my medications." "I stopped exercising so I won't fall." "I bought some new lamps for my home."

1. taking tai chi classes (exercise decreases chance of falls) 3.went to eye doctor 4.physician reviewed meds 6.i bought new lamps (better lighting to see) -AVOID wearing slippers and athletic shoes (deep treads)

The client is being treated for acute cholecystitis. The nurse administers morphine IV push and then administers ampicillin/sulbactam IV piggyback. The client reports throat itchiness and difficulty breathing. Which nursing actions are appropriate? Select all that apply. Auscultate the lungs. Stop the IV piggyback infusion. Give the client sips of water. Assess the client's throat. Prepare epinephrine for use.

1.auscultate lungs 2.stop iv piggyback 5.prepare epinephrine -insert large IV needle, infuse fluids rapidly -provide suction and oxygen

The nurse reinforces principles of asepsis to the LPN/LVN. The nurse intervenes if which actions are observed? Select all that apply. The LPN/LVN's clean glove touches the sterile tip of a syringe. The LPN/LVN talks over a sterile field. The LPN/LVN places sterile instruments on the edge of an opened sterile package. The LPN/LVN holds sterile objects below waist level. The LPN/LVN performs hand hygiene prior to donning sterile gloves. The LPN/LVN's clean hand touches the outside of a sterile glove.

1.clean glove touches sterile field 2.talks over sterile field (CANT TALK OVER STERILE FIELD 3.places sterile instrument on edge of border 4. hold sterile object below the waist 5.clean hand touches the outside of the sterile glove

allergic reaction symptoms select all 1.hypotension 2.rales 3.hypertension 4.rapid weak pulse

1.hypotension 2.rales 4.rapid weak pulse -urticia (hives), pruritis, dypsnea

The nurse on the surgical unit administers an incorrect dose of medication to the client. The nurse should take which of the following actions? Select all that apply: Record the dose of medication administered. Photocopy the incident report for the nurse's personal files. Perform an assessment of the client. Contact the physician. Chart any adverse reaction the client experienced. Submit the report to the risk manager within 48 hours.

1.record dose given 3.perform assessment of pt 4.contact physician 5.chart adverse reaction -need to submit report within 24 hours to risk manager

The circulating nurse assesses the client's care during the perioperative period. The nurse should follow up if which actions are observed? Select all that apply. Surgical nurse #1 removes the hair cap. Surgical nurse #2 shaved the client's hair at the operative site. The surgical assistant's shirt is outside the pants. Surgical nurse #3 reports a cough. The surgeon's face mask fits tightly on the face. Surgical nurse #4 has acrylic nails.

1.takes cap off 2.shaved hair (hair should be clipped) 3. shirt out off pants (risk for breaking sterile field) 4.reports cough (risk for infection) as well as sore throat 6.acryclic nails

The nurse prepares to insert an indwelling urinary catheter for a male client. Which actions are appropriate? Select all that apply. Utilize an 18 Fr size catheter. Retract and maintain retraction of foreskin. Hold penis perpendicular to body. Use sterile technique on insertion. Insert catheter 2 to 3 inches into urethra.

1.utilize 18 size catheter (women 14-16, men 16-18) -shouldnt maintain retracted penis because of paraphimosis-stuck foreskin emergency) 3.hold penis perpendicular 4.use sterile technique -insets 6-7 inches in

The client is diagnosed with myasthenia gravis. The nurse instructs the client about the disease. Which statement, if made by the client to the nurse, indicates the need for further teaching? "I should not drink alcoholic beverages." "I should not go places that are crowded." "I should try to stay calm." "I should use my hot tub daily."

should avoid heat (sunbathing, hot baths) -avoid large crowds, stressful events, alcohol

legionerres disease precaution

standard

pneumonia caused by staph precaution

standard

The nurse plans discharge care for the client diagnosed with recurrent cancer and who has lymphedema. Which client statements alert the nurse to a need for home health services? Select all that apply. "I use this magnifying glass when I need to read small print." "Sometimes I don't get to the bathroom in time." "My hands always shake when I try to pick things up." "My dentures don't fit so I don't wear them, but I eat just fine." "I can't feel a thing in my feet. It's been that way for a while." "I'm not able to get in the bathtub anymore."

2. sometimes i dont get to bathroom on time (care) 3. my hands always shake (OT) 4.my dentures dont fit (dietician) 5. I cant feel a thing in my feet (safety)

bilirbuin

Greater than 15 =bad -need phototherapy

Airborne Acronym

MTVS on AIR measles, TB, varicella/herpes zoster (shingles), SARS

pnuemocccol meningitis precaution

standard

cutaneous anthrax precaution

standard can only spread by touch of the anthrax

hep a

standard BUT CONTACT IF DIARRHEA incontinence

The nurse in the outpatient clinic recommends that a client receive the hepatitis A vaccine. Which of the following client statements caused the nurse to make this recommendation? "My mother developed hepatitis A 2 years ago." "I am a nurse in the hospital." "I received a blood transfusion when my child was born." "My church is sending me to Africa as a missionary."

My church is going to africa -need vaccine if going to area that had high levels of disease -also if have chronic liver disease or hemophilia

do you need to reestablish hep B immunity

NO just need proof of immunity

urine catheter insertion requires ____ gloves

sterile

wound cleaning sterile or nonsterile

sterile

Two days after her menses began, a 17-year-old high school student experienced sudden, severe, intermittent, left lower quadrant (LLQ) pain. Her mother drives her to a local outpatient clinic and tells the triage nurse her daughter needs something for menstrual cramps so she can participate in cheerleading tryouts. Which of the following responses by the nurse is BEST? 1."You will need to discuss that with the physician." 2."She probably should not be trying out for the cheerleading squad today." 3."Her signs/symptoms sound as if they involve more than her menstrual period." 4."You appear very concerned about your daughter's condition."

3. her sx sound as if they involve more than her period -dont pass buck and focus on signs and symptoms

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

Notify director of nursing -need to in order to start disaster plan

The nurse learns that a client recovering from an abdominal hysterectomy is being transferred from recovery to the medical/surgical unit. The nurse determines that the client's room assignment is appropriate if the client is placed in a room with which of the following clients? 1.A client recovering from a craniotomy to treat a brain abscess. 2.A client diagnosed with cellulitis of the left leg. 3.A client diagnosed with an MSRA wound infection. 4.A client recovering from gastric bypass surgery.

4.client recovering from gastric bypass

The nurse supervises a nursing team that consists of LPN/LVNs and nursing assistive personnel (NAPs). The client begins to experience a generalized tonic-clonic seizure while in a standing position and is assisted onto the floor. The nurse intervenes if which actions are observed? Select all that apply. 1.The LPN/LVN loosens constrictive clothing. 2.The NAP places a pillow under the client's head. 3.The LPN/LVN suctions secretions in the buccal cavity. 4.The LPN/LVN leaves the client supine. 5.The NAP restrains the client's extremities during the seizure. 6.The NAP closes the client's curtain.

4.leaves pt supine 5.restains client during seizure -want to loosen clothing, provide privacy, put in sidelying position want to suction pt during seizure

The hospital has just received word that a major disaster has occurred and a large influx of clients is expected in less than 1 hour. The nurse considers which of the following clients MOST appropriate for immediate discharge? An 84-year-old admitted 4 days ago with a diagnosis of a stage 3-pressure ulcer. A 72-year-old admitted 12 hours ago with a diagnosis of pyelonephritis. A 66-year-old client 5 days postop after a total hip replacement. A 45-year-old client 24 hours postop after a vaginal hysterectomy.

5 days postop after total hip replacement -next stable pt is the 24 hour postop hysterectomy

The nurse in the outpatient clinic administers the Mantoux test to a client who is HIV positive. The nurse determines that the test is positive if which of the following is observed? A 10-mm area of induration. A 10-mm area of erythema. A 5-mm area of induration. A 5-mm area of erythema.

5mm induration

The public health nurse assesses a patient who is complaining of a persistent cough with blood-tinged sputum and of night sweats. Which of the following actions should the nurse take FIRST? Assess the patient's vital signs, including oxygen saturation. Place the patient on 2 L oxygen per nasal cannula. Assist the patient in putting on a mask. Assess the patient's lung sounds.

Assist the pt in putting on a mask -preventing spread of infection is priority

raditation exposure does/doesnt need decontamination

DOESNT need decontamination

The nurse prepares for the admission of a patient diagnosed with diabetes and a latex allergy. The only private room on the unit is occupied by a patient diagnosed with tuberculosis. The nurse should take which of the following actions when assigning the new patient to a room on the unit? Transfer a patient diagnosed with tuberculosis to a room with a patient diagnosed with bronchitis, and then clean the private room for the patient with latex allergy. Admit the patient diagnosed with latex allergy to a room with a patient diagnosed with Parkinson's disease, and treat both patients as being latex-sensitive. Admit the patient diagnosed with latex allergy to a room with a patient diagnosed with diverticulitis, and keep the beds and all equipment at least 3 feet apart. Admit the patient diagnosed with latex allergy to a room with a patient diagnosed with diabetes who has a Foley catheter and is receiving oxygen.

admit pt to room w/ parkinsons and treat both as latex sensitive -foley and oxygen equipment have latex -3 feet apart is only droplet

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

are you concerned you may be infected w/ TB? -addresses pt's concern

An RN arrives at work stating, "My throat hurts and I have a temperature of 99.5°F (38°C)." This RN is one of two RNs scheduled to work the shift with no additional support staff. Which of the following actions by the healthy nurse is MOST appropriate? Refuse to work with the RN with the sore throat. Recommend to the RN with the sore throat to obtain a throat culture before accepting an assignment. Ask the charge nurse from the previous shift to send home the RN with the sore throat. Arrange for coverage for the RN with the sore throat while a throat culture is obtained.

arrange for coverage for the RN with the sore throat while a throat culture is obtained -if positive cant work until 24 hours on antibiotics

The nurse prepares to discharge a client diagnosed with AIDS. The client is going to her parents' home so that they can take care of her. Which of the following actions should the nurse take INITIALLY? Refer the client for home care. Assess if the client and her parents understand the dosing schedule and side effects of the medication. Ask the client about what kind of help she needs from her parents. Encourage the parents to join a support group.

ask pt about what kind of help she needs from her parents -assess what is provided so can see what other resources she needs

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

assess abdominal pain

The nurse cares for a client preparing for surgery. Thirty minutes after administering the preoperative medication, the nurse observes a nursing assistant ambulate the client to the bathroom. Which of the following actions should the nurse take FIRST? Assist the client back to bed. Ask the nursing assistant if the client had difficulty walking. Determine why the nursing assistant ambulated the client. Ensure that the nursing assistant receives the appropriate training.

assist client back to bed r/t risk of falls

After a major power outage, a confused client with an unsteady gait arrives at a portable emergency response station. Which of the following actions should the nurse take FIRST? Determine where the client lives. Assess the client's level of consciousness. Assist the client to the nearest chair. Assign the client a triage number.

assist to chair -safety before assessment

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

breathes in chemical affects resp status

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

call plumber to set hot water to 100

3yr old and stairs

can go up and down alone

The nurse cares for a client immediately following a pancreatectomy. The client returns to the surgical unit with a drainage tube attached to low suction. The nurse notes that there has been no drainage since the client's return. Which of the following actions should the nurse take FIRST? Notify the physician. Check for a kink in the drainage tube. Increase the suction. Obtain the client's vital signs.

check for kink in drainage tube

aseptic

clean

urine catheter removal requires ___

clean gloves

group A step wound precaution

contact

open infected wound needs ---- precaution

contact

scabies precaution

contact

RSV precautions

contact-private room w/ sleeping accomidations for parents

The nurse instructs the mothers of toddlers about safety precautions for their children's eyes, ears, and noses. Which of the following is the MOST important statement for the nurse to include? "Teach your child to blow the nose first with one nostril closed and then the other." "Cotton-tipped applicators should be used only on the outer ear." "Getting a foreign object out of the ear is best done by irrigation." "If you need to give eardrops, make sure the solution is cold rather than hot."

cotton tipped applicators should only be used for outer ear -dont always use irrigation-contraindicated if veggie because will swell w/ fluid

The home care nurse visits the home of a client with heart failure. During the nurse's visit, the client's grandchildren come to visit. The nurse should intervene if which of the following is observed? The client's 4-month-old grandchild plays with a rattle that is cracked. The client's 3-year-old grandchild goes up and down the stairs alone. The client's 5-year-old grandchild has an imaginary playmate. The client's 7-year-old grandchild cuts his meat using a table knife.

cracked rattle -aspiration risk

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

do you wear glasses r/t want to assess if other material went into pt's eye

The assigned nurse prepares a nursing home unit for the client who had a stroke resulting in right-sided paralysis. Which action by the nurse is MOSTappropriate? Post a sign stating, "Keep floor dry and free of debris." Post a sign stating, "Do not use client's right arm for lifting." Post a sign stating, "Client is hard of hearing." Post a sign stating, "Client is paralyzed on the right side."

dont use clients right arm for lifting r/t possible dislocation -being paralyzed on right side doesnt specify instructions

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

double bag the suitcase and insects -want to contain insects

Group A strep pnuemonia

droplet

influenza precaution

droplet -mask

Menengitis precaution

droplet -mask, private room, can leave door open

meningoccal pneumonia

droplet until 24 hours after therapy

Hospital administration decides the psychiatric unit will move to a former medical-surgical unit in 2 months. The psychiatric nurse manager goes to the new unit to assess its structure. Which of the following MOST concerns the nurse? The lights and floor coverings in the hallways. The location of the nursing station in relationship to the patient rooms. The fixtures in the bathrooms in patient rooms. The availability of a large central room for unit meetings and socialization.

fixtures because can hang themselves

A 45-year-old patient with leukopenia is in protective isolation. The nurse should intervene if which of the following is observed? The patient's wife enters the patient's room wearing a mask, gown, and gloves. The patient's food is delivered to the patient's room on china with nondisposable eating utensils. A basket of fresh fruit is delivered to the patient's room. A large card signed by the patient's coworkers is delivered to the patient's room.

fresh fruit is delievered -no fruit or plants allowed in room r/t risk of infection -clean bathroom daily, can use china/silverware, limit visitors to healthy adults -mucus membane should be assessed Q8 hrs

PPE off

gloves, eye protection, gown, mask

PPE on

gown, mask, eye protection, gloves

The nurse cares for clients in the senior citizens facility. The client relates to the nurse that, "I had pneumonia once, and I don't want to get it again." To develop an effective teaching plan for this client, it is most important for the nurse to obtain an answer to which question? "How often do you cough and deep breathe?" "Have you received a flu shot this year?" "Do you avoid crowds?" "How much sleep do you receive each night?"

have you received a flu shot this year -assess flu and pnuemmocal vaccine

During a flood, two ambulances arrive at an emergency substation at the same time. One contains a 2-year-old near drowning victim on a ventilator. The other contains an 80-year-old client with a left-sided CVA who is conscious and has a blood pressure of 220/130. Which patient should the nurse see INITIALLY? The 2-year-old because she is on a ventilator. The 80-year-old because he is hypertensive. The 2-year-old because she is a victim of the flooding. The 80-year-old because he is older.

hypertensive pt -unstable -no indication that ventilator pt is unstable

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

i only use super absorbent tampons when i menstruate (cause vaginal drying) -tampons should be changed Q4 hours signs of toxic shock-fever, NV when menstrauting

The nurse supervises the staff caring for clients on the medical/surgical unit. The nurse observes the student nurse enter wearing a gown, gloves, and a facemask. The nurse determines that the precautions are correct if the student nurse is caring for which of the following clients? An infant diagnosed with respiratory syncytial virus. A school-aged child diagnosed with hepatitis A. A teenager diagnosed with toxic shock syndrome. A teenager diagnosed with influenza.

influenza gets droplet

The nurse observes that a family member enters an adult client's room, leaves the door open, and stands 3 feet from the client. The nurse determines that these precautions are appropriate if the client is diagnosed with which of the following? Haemophilus influenzae pneumonia. Localized herpes zoster. Lyme disease. Influenza.

influenza is droplet

The nurse assesses clients on the medical-surgical unit. The nurse identifies which client is at GREATEST risk for accident and injury? The client diagnosed with rheumatoid arthritis. The client diagnosed with a stroke of the right hemisphere. The client recovering from a bilateral oophorectomy. The client recovering from a right hip replacement.

stroke of right hemisphere -right sided stroke worse= vision and impulsive behavior, poor attention span

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

make list of all clients breathing and iv meds for next 12-15 hours -never leave unit -organization important for vital care

The nurse in the pediatric clinic makes a follow-up call to the mother of a school-aged child diagnosed the previous day with rubella (German measles). Which statement by the mother should the nurse respond to FIRST? "My sister-in-law is coming to visit next week. She just found out that she is pregnant." "I have heard measles can cause serious complications. I do not know how to protect my child." "My child is so upset about missing the class trip. It is my fault for not having my child immunized." "My child feels very warm. I am going to give my child some aspirin to decrease the fever."

my child feels warm so im going to give aspirin -rubella =droplet precaution -is tetragetic to pregnant women

The nurse performs a health screening at a senior citizen facility. The client has been taking oral iron supplements for a month and reports constipation. The nurse should adapt a diet plan to include which food? Oatmeal, green beans, and celery. Strawberries and mushrooms. Grits, orange juice, and cheddar cheese. Pasta, buttermilk, and bananas.

oatmeal green beans and celery all high in fiber FIBER=GREEN VEGGIES AND GRAINS

A patient is brought to the emergency department by EMS with a blood glucose level of 32 mg/dL. The patient received 25 cc of 50% dextrose in water before arrival. While assessing the patient, the nurse instructs the patient care tech to do which of the following? Recheck the patient's blood glucose. Obtain orange juice for the patient. Administer 1 mg of glucagon IM. Obtain an EKG on the patient.

obtain oj for pt -need to give for moderate hypoglycemia

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

on right side with head elevted -think want to empty with gravity

Post tube feeding position

on right side, head elevated

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

proper nutrition -school age child r/t threat of obesity

The nurse admits a client with nuchal rigidity and photophobia. Which of the following actions should the nurse take FIRST? Place client on droplet precautions. Monitor for increased intracranial pressure. Prepare the client for a lumbar puncture. Set up seizure precautions.

put pt on droplet precaution -nuchal rigitity = meningitis -will eventually need seizure precautions

The nurse observes a nursing assistant providing care on the medical/surgical unit. The nurse should intervene if which of the following is observed? The nursing assistant performs perineal care for a client diagnosed with a cerebrovascular accident. The nursing assistant removes dead leaves from a plant in the client's room. The nursing assistant removes the contact lenses from a client with right-sided weakness. The nursing assistant collects a clean catch urine specimen from a client diagnosed with pneumonia.

removes dead leaves from pts room -shouldnt handle both

The industrial nurse supervises the health care needs at a local plant. It is announced on the news that a device has exploded in a heavily populated area away from the plant and that individuals near the site have become ill. Several hours later, workers at the plant come to the nurse and demand antibiotics to protect them against potential effects of the device. Which of the following responses by the nurse is MOST appropriate? "I cannot administer medication without a physician's order." "Tell me about how you are feeling." "The cause of the illness has not been identified." "Do you have any allergies to medications?"

tell me how youre feeling

The nurse visits the home of a client diagnosed with a right-sided cerebrovascular accident. The client's 3-year-old grandchild comes to visit during the nurse's visit. The nurse should intervene if which of the following is observed? The child colors with crayons and markers. The client offers her grandchild apple juice. The child goes into the bathroom alone to use the toilet. The client gives her grandchild a penny when the child says please and thank you.

the client gives her grandchild a penny when the child says thanks -3 yr old can use bathroom by themselves

The nurse prepares a client for discharge requiring oxygen therapy at home. It is MOST important for the nurse to assess for which of the following? The amount of oxygen required within a 24-hour period. How to maintain the equipment. The client's understanding of home oxygen therapy. Adequate personnel available to monitor oxygen therapy.

the clients understanding of home oxygen

The nurse in the outpatient clinic counsels a client diagnosed with genital herpes. The client states, "I don't know how I keep getting reinfected because I am really careful." Which of the following responses by the nurse is BEST? "What do you mean, ' I am really careful'?" "The virus remains in your body in a dormant state." "Are you sure that you protect yourself adequately?" "Have you notified all of your sexual contacts?"

the virus remains in your body in a dormant state -once get herpes always have herpes -abstain till lesions have healed

community aquired pneumonia typically follows after _____

viral infection or flu

The mother of a 5-month-old contacts the nurse to report that she has a dry cough, fever, headache, and muscle aches. The client breast-feeds her infant. Which of the following actions by the nurse is BEST? Suggest the client discontinue breastfeeding during the illness. Ask the client to increase her fluid intake. Instruct the client to wear a surgical mask. Inform the client to uncover her breasts before washing her hands.

wear a surgical mask while feeding not going to stop breastfeeding

The young adult comes to the outpatient clinic reporting vaginal itching. Which recommendation, if given to the client by the nurse, is most appropriate? "Supplement your diet with yogurt and dairy products." "Douche with an over-the-counter preparation." "Wash the area with soap and water several times a day." "Wear underwear that is lined with a cotton crotch."

wear underwear lined w/ cotton since absorbant diet has nothing to do with vaginal bacteria

The nurse supervises care for a client diagnosed with a stage III pressure ulcer of the sacrum with foul smelling purulent drainage. The nurse should intervene if which of the following is observed? The LPN/LVN enters the room wearing a gown and gloves. The nursing assistant enters the room wearing a mask. The client's family offers him a milkshake. The staff lifts the client to reposition him.

wearing a mask -safe to lift patients when repositioining

+ Brudzinski sign

when flex neck cause knees and hips to flex as well

Kernig sign

when pt hip and leg are flexed if extended out will cause pt PAIN