Ch. 24 27 29 ( NUR 151)

The nurse is caring for a client who is to have a sterile dressing change to a wound. A student nurse enters the client's room and notices the nurse preparing the sterile field. After reviewing the image, which response by the student nurse to the nurse is the most accurate understanding of this procedure?

"The way you are doing it helps to minimize contamination of the non-waterproof side." -The sterile drape is to be positioned with the drape on work surface with the moisture-proof side down.

The nurse is caring for an older adult client who sees several different health care providers and specialists. Which question will the nurse ask?

*"Do you get all of your medications filled at the same pharmacy?"

The charge nurse has just completed an inservice with a group of nursing students. One nurse student asks, "Why do I have to know how to give medications in different ways. I thought the unlicensed assistive personnel (UAP) performs those skills?" What is best response by the charge nurse?

*"Entry-level nurses will perform basic skills appropriate to the scope of practice and that includes administering medications through various routes."

The nurse is administering the first dose of an intravenous infusion of an antibiotic. Which statement made by the client is cause for concern?

*"I feel like my back and arms are itching." -IV infusions have an immediate effect. The nurse should instruct the client to report any difficulty in breathing or signs of reaction such as itching.

The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective?

*"I will put a layer of cloth between my skin and the ice pack."

A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which statement indicates that the client understands?

*"I will squeeze the chamber and apply the cap to maintain negative pressure." -The Hemovac drain chamber should be squeezed and the cap applied to maintain negative pressure. The negative pressure pulls the drainage into the collection chamber. This negative pressure must be maintained continuously unless the drain is being emptied. The drain must be checked and emptied at least every 4 hours.

The nurse is preparing a sterile field for a procedure in the client's presence. Which is the most appropriate instruction to give the client in this situation?

*"I've set up this sterile field for your procedure, so please do not touch anything around the tray."

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?

*"Is your child breathing at this time?" -Initial treatment for a victim of suspected poisoning involves maintaining breathing and cardiac function, so the nurse will ask about the child's respiratory status.

The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include?

*"It provides a way to remove drainage and blood from the surgical wound."

A client who has been prescribed an inhaler points to the spacer and asks, "What is this for?" What is the appropriate nursing response?

*"Medication stays in the chamber so you can continue to inhale it."

The nurse just completed a refresher course on parenteral drug administration. Which statement by the nurse indicates that teaching was effective?

*"Reconstitution is the process of adding liquid, known as diluent, to a powdered substance."

The nurse is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching?

*"Reinforced adhesive skin closures will hold my wound together until it heals." -After a cesarean birth, a client will be sutured and have staples put in place for a number of days. The health care provider or nurse will remove staples.

The nurse is assessing an adolescent with an annual physical. The parent reports noticing a change in the child's behavior lately, including mood swings, withdrawal from the family, and failing school grades. The parent does not know what to do and asks the nurse for guidance. What is the most appropriate guidance from the nurse?

*"These could be signs of substance use. Open communication and seeing a counselor who specializes in substance use would be beneficial."

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surigical wound during a dressing change. What instructions should the RN provide the LPN regarding this action?

*"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator."

A client is taking numerous eye drops to prepare for cataract surgery. Which teaching about ophthalmic application will the nurse provide?

*"Wait 5 minutes between instillation of different types of eye drops." -The nurse will teach the patient to wait 5 minutes between instillation of different types of eye drops to facilitate best absorption.

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?

*"Your wound will heal slowly as granulation tissue forms and fills the wound."

A client with a complex cardiac history has been prescribed digoxin 0.0625 mg PO. The drug is available as 125 mcg tablets. How many of the tablets will the nurse administer?

*0.5.

The nurse is working the night shift in the ER when an ambulance arrives carrying a man s/p motor vehicle accident (MVA). His initial BP is 100/56 and the nurse notes that he is bleeding heavily from a laceration on the forehead. Fifteen minutes later, the nurse reassesses the client and finds that his BP is 95/58. What IV fluid would the nurse expect to be ordered?

*0.9% NS- Isotonic fluids are used to increase blood pressure secondary to hypovolemia.

The nurse is preparing supplies for a tuberculosis screening. The nurse should choose which syringes and needles?

*1 mL syringe; ½-inch (1.25-cm), 26-gauge needle. -For a tuberculosis screening, the nurse should choose a 1 mL syringe with a ½-inch (1.25-cm), 26-gauge needle.

A nurse is administering a subcutaneous injection to a client. What is the common maximum volume of a subcutaneous injection?

*1 mL- The volume of a subcutaneous injection is usually up to 1 mL.

The nurse is preparing to administer an allergy test intradermally. At what angle will the nurse plan to insert the needle into the client?

*10 to 15 degrees- Intradermal injections are given at a 10- to 15-degree angle.

The nurse is preparing to administer a tuberculin test. At which angle is the nurse expected to instill the drug?

*15-degree angle- A 15-degree angle is correct, as this allows the drug to be injected between the layers of the skin.

The health care provider prescribes ciprofloxacin 500 mg PO q12h for a pediatric client with bronchial pneumonia. The nurse has liquid ciprofloxacin 250 mg/10 mL on hand. How many mL would the nurse dispense? Fill in the blank. Record your answer using a whole number.

*20 Order/ Available 500/250= 2 (10)= 20

How many times should you check a medication?

*3 times. 1.When you pull the medication 2. Hold above MAR & check Med against MAR. 3. Comparing MED w/ MAR at patients bedside.

How many factors affect drug action?

*8 1- Developmental factors 2-WT 3-Gender 4-Culture 5-Genetic Factors 6-Pychological Factors 7-Pathology 8-Environment P.827

The nurse is preparing to administer insulin to an obese client. At what angle will the nurse plan to insert the needle into the client?

*90 degrees- Insulin injections are given subcutaneously to clients with obesity at a 90-degree angle.

The nurse is preparing to insert an intravenous needle in a 1-year-old child for a one-time administration of fluids due to dehydration. Which needle would the nurse likely select?

*A 23-gauge winged infusion set. -Winged infusion or small vein needles may be used for short-term or one-time infusion therapies or may be used with infants and small children. These are short, beveled needles with plastic flaps or wings.

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true?

*A Penrose drain promotes passive drainage into a dressing. -A Penrose drain is an open drainage system that promotes passive drainage of fluid into a dressing.

The nurse is providing safety teaching to the family of an older adult client. Which finding in the client's home will the nurse teach the family to address?

*A hair dryer is placed next to the sink.

What is a Meter-Dose Inhaler?

*A meter-dose inhaler has a canister that contains medication under pressure.

What is a normal WBC count?

*A normal white blood cell count is 5,000 to 10,000 cells/mm3.

A nurse is performing safety assessments in a health care facility. Which statements reflect considerations a nurse should keep in mind when assessing a client for safety? Select all that apply.

*A person with a history of falls is likely to fall again. *Some people are more at risk for accidents than others. *A medication regimen that includes diuretics or analgesics places an individual at risk for falls.

Stage I Pressure Ulcer-

*A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue.

Stage II Pressure Ulcer-

*A stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II injury could present as a blister, abrasion, or shallow crater.

Stage III Pressure Ulcer-

*A stage III injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. -Slough that may be present does not obscure the depth of tissue loss. Injuries at this stage may include undermining and tunneling.

A medication order has ac written after the medication dosage. What does ac stand for?

*AC= Before meals.

The nurse working on the medical-surgical unit is caring for four clients with varying needs. In which situation(s) would it be acceptable to use alcohol-based handrub? Select all that apply.

*After removing gloves following a dressing change *Before assessing a client's vital signs and performing edema measurement *Before handling an invasive device for client care

When the client demonstrates a rash 30 minutes after taking a dose of penicillin, the nurse recognizes that the client is likely demonstrating which type of drug reaction?

*Allergy- Allergic reactions result from an immunologic response to a substance to which the client is sensitized.

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?

*An infant's skin and mucous membranes are easily injured and at risk for infection.

What is the common maximum Volume of Intramuscular Injection?

*An intramuscular injection is the administration of up to 3 mL of medication into one muscle or muscle group.

The client asks the nurse how to administer medication purchased over the counter for relief of arthritis pain. The nurse reviews the medication and determines that it is to be applied topically. Which instructions should the nurse provide?

*Apply the medication to clean, dry skin of the affected area using gloves.

The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation?

*Ask to examine the client alone in order to speak to her privately.

What does Aspirate (regarding injections) mean?

*Aspiration-is the process of pulling back on the syringe plunger by applying negative pressure for 5-10 seconds after the needle has been inserted into tissue, but before administration of the medication.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

*Assess the client's wound and vital signs. -First, the nurse should assess the client. The nurse needs to assess the wound, assess if the therapy is working properly, assess the client's vital signs, and assess the pain.

When preparing to administer a second dose of a prescribed vaginal suppository, the client reports discomfort in the vaginal area. What should the nurse do next?

*Assess the vaginal area.

A school-age child is admitted to the emergency room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client?

*Assessment of vital signs and respiratory status. -Assessment after a head injury includes immediate evaluation of airway, breathing, and circulation.

A nurse is caring for a client who is being tube fed. What care should the nurse take when administering medications through an enteral tube?

*Avoid crushing sustained-release pellets. -When administering medications through an enteral tube for a tube-fed client, the nurse must avoid crushing sustained-release pellets because keeping them whole ensures their sequential rate of absorption.

The nurse is caring for an older adult client. Which situational assessment findings establish the need for interventions? Select all that apply.

*Bedside table with client's personal items is at the foot of the bed. *Oxygen by nasal cannula in place; tubing on floor; flow meter at ordered 3 L. *Call light is at top of bed under the pillow.

What is Bisacodyl?

*Bisacodyl- is a rectal suppository used for softening stool.

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply.

*Client-centered care *Teamwork and collaboration *Quality improvement (QI)

A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first?

*Conceal IV tubing with gauze wrap.

The nurse is preparing to administer two IV medications. What is the appropriate nursing action?

*Consult a current drug reference book for IV compatibility.

The nurse is preparing to give medications to a client with anxiety. The order indicates that the client is to have bupropion, 7.5 mg by mouth twice daily. What is the appropriate nursing action?

*Contact the health care provider for order clarification. -The nurse should contact the health care provider to verify the order. Bupropion and buspirone are drugs that have look-alike and sound-alike properties but are different in indication.

The nurse is caring for a client with a secondary urinary tract infection for which amoxicillin 250 mg PO has been prescribed. The nurse recognizes this as a drug that is routinely administered every 8 hours; however, the prescription does not state the frequency of administration. The health care provider is no longer present. What is the appropriate nursing action?

*Contact the health care provider to clarify the prescription by reading back to the provider, update the electronic medical record (EMR) while on the phone, then document it was a phone prescription.

A nurse is administering an adult client's ordered antipsychotic drug intramuscularly. What would be the most appropriate site for administration?

*Deltoid

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?

*Desiccation- Desiccation is localized wound dehydration.

A client with a new diagnosis of glaucoma (increased pressure within the eye) has been prescribed a medication that is to be administered by an eye drop. Which action should the nurse perform?

*Ensure that drops of the medication fall onto the client's conjunctival sac. -Eye drops should be applied to the conjunctival sac.

What is Enteral Tube Feeding?

*Enteral feeding refers to intake of food via the gastrointestinal (GI) tract. The GI tract is composed of the mouth, esophagus, stomach, and intestines.

The nurse is educating health care providers on implementation of a hospital disaster plan. What consideration should the nurse prioritize?

*Establish the nurse's role during a disaster. -During a disaster nurses will have multiple roles. In addition to their clinical knowledge, they may be responsible for triage, counseling and various other duties.

In a non-infected wound, how often will the nurse change the dressing for a client with negative pressure wound therapy?

*Every 48 to 72 hours. -In a non-infected wound, the negative pressure dressing should be changed every 48 to 72 hours.

What is Evisceration?

*Evisceration- is complete separation of the wound, with protrusion of viscera through the incisional area.

Infants are vulnerable to injuries related to?

*Falling from the bed is common in infants.

A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply.

*Fingers with quick capillary refill *Warm hand *No finger numbness or tingling -The nurse should monitor, observe, and document for quick capillary refill of fingers, normal radial pulse, normal skin color, no swelling, numbness, and tingling of the hand and fingers.

A client has presented to the emergency department after splashing a chemical in the eyes. When managing the injury, what should be included in the plan of care?

*Flush the eyes with water for 10 minutes. -If poisonous substances have been instilled into the eye, immediate irrigation with lukewarm water for 10 to 15 minutes may reduce harmful effects.

Which piece of personal protective equipment (PPE) should be removed first?

*Gloves -The order for removal of PPE is gloves, goggles, gown, and respirator. If removal of PPE is not in that order, contamination of the nurse can occur.

What does Half-Life mean?

*Half-life- is the amount of time it takes for 50% of the blood concentration of a drug to be eliminated from the body.

When educating families on fire safety in the home, which information is important for the nurse to emphasize?

*Have a meeting place outside the home in case of fire.

Healing by Secondary Intention-

*Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base.

A nurse is caring for a client who refuses to take the prescribed medication, stating that she is allergic to it. What should the nurse do when the client refuses to take the medication? Select all that apply.

*Identify the reason for not administering. *Circle the scheduled time on the MAR. *Report the situation to the prescriber.

Which situation accurately describes a recommended guideline when administering oral medications to clients?

*If a child refuses to take medication, crush the medication, if allowable, and add to a small amount of food.

The nurse is preparing to administer an allergy test via an intradermal injection. Which injection site would be most appropriate in this situation?

*Inner surface of the forearm. -Sites commonly used for intradermal injections are the inner surface of the forearm and the upper back, under the scapula.

What are intradermal injections?

*Intradermal Injection (ID)- is a shallow or superficial injection of a substance into the dermis, which is located between the epidermis and the hypodermis. *given at a 10-15 degree angle.

What is an Intradermal Route?

*Intradermal Route (IR)- is injecting the drug between the layers of the skin.

What is the Volume for Intradermal Injections?

*Intradermal injections are commonly used for diagnostic purposes in small volumes, usually 0.01 to 0.05 mL.

What is the Intramuscular route?

*Intramuscular (IM) route- is reserved for drugs to be injected in the muscle. *90-degree angle -The deltoid muscle of the shoulder are common injection sites.

What is the Intravenous Route?

*Intravenous (IV) route- is reserved for drugs to be instilled into veins. *120-degree angle.

Transdermal medication:

*Is A medication that is designed to produce systemic effects (occuring in the tissue distant from the site) and is absorbed through the skin.

A nurse is explaining to a client the correct method of using a metered-dose inhaler when self-administering a prescribed dose of medication. What is a feature of a metered-dose inhaler?

*It is a canister that contains pressurized medication. -A meter-dose inhaler has a canister that contains medication under pressure.

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?

*Keep the swab and the inside of the culture tube sterile.

A nurse preparing medication for a client is called away to an emergency. What should the nurse do?

*Lock the medications in a cart and finish them upon return. -Once medications have been prepared the nurse must either stay with the medications or lock them in an area such as the medication cart. -The medications should never be left unattended or placed back in their containers. -Another nurse cannot administer medications that have been prepared by the first nurse.

What is Maceration?

*Maceration- is localized wound overhydration or excessive moisture.

Maturation Healing-

*Maturation is the final stage of full-thickness wound healing.

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action?

*Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.

What best describes the nurse's role in disaster preparedness?

*Multiple roles, including triage and the distribution of resources. -Nurses will perform multiple roles when assisting with a disaster, including triage, procedures, counseling, and distribution of resources.

What is Necrosis?

*Necrosis- is death of tissue in the wound.

If the dosage is inappropriate for a client, who is responsible?

*Nurse

What is Oxymetazoline?

*Oxymetazoline- is a nasal decongestant used to alleviate congestion.

What does Parenteral mean?

*Parenteral Meds- Parenteral drugs are most commonly administered as an injection without entering the mouth, stomach, intestines, rectum or respiratory tract. The parenteral route allows medications to be directly absorbed into the body quickly and more predictably.

What does Peak Level mean?

*Peak level- is the highest plasma concentration.

The nurse is teaching the caregiver of an adolescent child about safety. Which teaching will the nurse include?

*Peer pressure causes children of this age to take risks.

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priority recommendation for this client?

*Placing the client in a bed with a bed alarm.

The chemotherapy client has been admitted for thrombocytopenia. Which blood product will the nurse anticipate administering?

*Platelets

School-aged children are vulnerable to injuries related to?

*Play-related injuries are commonly seen in school-age children

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take?

*Pull the fire alarm lever.

What does Purulent drainage look like?

*Purulent drainage has various colors, such as green or yellow; this drainage indicates infection.

What does Reconstitution mean?

*Reconstitution- is the process of adding liquid, known as diluent, to a powdered substance.

What is a Refilled Cartridge?

*Refilled Cartridge- A sealed glass cylinder of parenteral medication with an attached needle.

The nurse on a medical-surgical unit notices smoke from a client's room. Upon entering, the nurse notes that the curtain in the room is on fire. What should be the nurse's first action?

*Remove the client from the room.

Which action is the best example of a nurse donning/removing protective equipment properly?

*Removing respirator after leaving client's room.

A nurse brings a client the prescribed dose of medication and finds that the client is not in the unit. What should the nurse do in this case?

*Return the medication to the medication cart or medication room.

A nurse is preparing to administer a scheduled dose of enteric-coated ASA to a client who has a history of angina. When preparing the medication, the nurse is careful to check the five rights of medication administration. The five rights include which of the following?

*Right time -The five rights consist of the right client, right drug, right dose, right route and right time.

What is ringworm caused by?

*Ringworm is caused by a fungal infection. Fungi include yeasts and molds, which cause infections in the skin, mucous membranes, hair, and nails.

The nurse is creating a plan of care for the older adult who has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care?

*Risk for Poisoning related to poor eyesight and the inability to read medication labels.

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?

*Rotate the swab several times over the wound surface to obtain an adequate specimen. -The nurse should press and rotate the swab several times over the wound surface. The swab should be inserted into the culture tube at the bedside, immediately after collection.

What does S/P mean?

*S/P- Status Post (After).

What does sanguineous drainage look like?

*Sanguineous drainage consists of red blood cells and looks like blood.

What does Serous drainage look like?

*Serous drainage is a clear drainage consisting of the serous portion of the blood.

Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk?

*Social pressure- As adolescents explore opportunities, they may know that certain behaviors are unsafe, but social pressure can persuade them to act against their better judgment.

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?

*Stage II- A stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II injury could present as a blister, abrasion, or shallow crater.

Stage IV Pressure Ulcer-

*Stage IV injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling.

The nurse is caring for a client who developed a urinary tract infection while hospitalized. What intervention(s) will the nurse initiate to care for this health care-associated infection? Select all that apply:

*Standard precautions such as gloves and hand hygiene *Move client to a private room for safety precautions *Transmission-based precautions including proper disinfecting of equipment

A client is receiving a secondary infusion of a new antibiotic. After 5 minutes of administration, the client reports itching and appears flushed. What is the first nursing intervention?

*Stop the infusion.

What is the Subcutaneous Route?

*Subcutaneous Route- is reserved for drugs to be injected beneath the skin but above the muscle. -The abdomen and anterior aspect of the thigh are common injection site.

Where are SUBLINGUAL Meds placed?

*Sublingual medications are placed under the tongue.

A health care provider who just arrived on the unit gives a verbal order to the nurse regarding a nonemergent client situation. What is the nurse's appropriate response?

*Tactfully request the provider to input the order into the computerized provider order system.

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client?

*Take the restraints off, stay with her, and talk gently to her.

Tertiary Intention-

*Tertiary intention occurs when there is a delay between injury and wound closure. The delay may occur when a deep wound is not sutured immediately or is left open until no sign of infection is evident.

A client limps into the emergency department and states, "I stepped on a nail and did not have shoes on. Now I can barely walk." What types of concern does the nurse anticipate the client will have?

*Tetanus, infection, wound care, and pain control.

Hemovac Drain Chambers-

*The Hemovac drain chamber should be squeezed and the cap applied to maintain negative pressure. The negative pressure pulls the drainage into the collection chamber. This negative pressure must be maintained continuously unless the drain is being emptied. The drain must be checked and emptied at least every 4 hours.

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse?

*The alternative measures attempted before applying the restraints.

A client has been diagnosed with a glioblastoma and the care team has determined that this brain tumor is inoperable. Which aspects of the the client's subsequent care demonstrate adherence to the Quality and Safety Education for Nurses (QSEN) competencies? Select all that apply.

*The care team meets with the client and family promptly to identify their preferences for treatment. *The care team balances the best available evidence about glioblastoma treatment with the client's preferences. *Nurses proactively identify threats to the client's safety that may occur as treatment is provided. *Each member of the care team uses the best available technology to organize and provide

Stages of infection:

*The correct sequence of the stages of infection are (1) incubation period (the period between exposure to an infection and the appearance of the first symptoms.), (2) prodromal stage (signs & symptoms are present/more severe), (3) full stage of illness, and (4) convalescent period (healing period).

Dermis-

*The dermis contains the nerves, hair follicles, blood vessels, and glands.

The nurse correlates the metric system as the most accurate method utilized to administer medications for which reason?

*The dosage prescriptions of medications most often use this system as it is measured in 10s and can be easily converted between measurements.

Epidermis-

*The epidermis is the outer layer that protects the body with a waterproof layer of cells.

Which should be documented by the nurse?

*The fact that sterile technique was used for a given procedure.

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation?

*The hospital must bear any costs incurred for treating the client's injury. -If "never events" occur while a client is hospitalized, the cost of the care associated with that event will not be paid by CMS, but will be borne by the hospital.

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process?

*The nurse details the client's response and the examination and treatment of the client after the incident.

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?

*The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?

*The nurse should question the client about the source of the bruises.

A postoperative client's medication administration record (MAR) provides for PRN administration of a number of analgesics by various routes. Which action should the nurse take to assess the client's pain to determine the appropriate analgesic to administer?

*The nurse will have the client rate pain on the pain scale of 1 to 10 and proceed accordingly.

A nurse was injured when a client with Alzheimer disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate?

*The report provides a detailed and objective account of the circumstances before, during, and after the event.

Which statement best describes the nurse's rationale for selecting the ventrogluteal site when using the Z-track technique for administering an injection?

*The ventrogluteal site provides a location with the capacity for depositing and absorbing the drug.

What does Therapeutic Range mean?

*Therapeutic range is the concentration of drug in the blood serum that produces the desired effect without causing toxicity.

What is the term used for the concentration of drug in the blood serum that produces the desired effect without causing toxicity?

*Therapeutic range.

What does Thrombocytopenia mean?

*Thrombocytopenia- is a condition in which you have a low blood platelet count.

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow?

*Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

What is Timolol?

*Timolol- is an eye drop used to treat glaucoma.

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?

*To splint the area when engaging in activity. -To support the underlying tissues and decrease discomfort, the nurse should teach the client to splint the area when engaging in activities such as changing positions, coughing, or ambulating.

What does Trough Level mean?

*Trough level- is the point when the drug is at the lowest concentration.

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.

*True -A Penrose drain is an open drainage system that exits the skin through a stab wound. The purpose a Penrose drain is to provide a sinus tract for drainage.

What is a Turbo-Inhaler?

*Turbo-Inhaler-which is a propeller-driven device that spins and suspends a finely powdered medication. Turbo-inhaler- has propellers that get activated during inhalation.

The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options.

*Turn on the faucet and adjust force and temperature of the water. *Wet the hand and wrists. *Apply soap. *Wash the palms and backs of the hands for at least 20 seconds. *Pat the hands dry with a paper towel. *Turn the faucet off with a paper towel.

A client requests more medication for pain at the surgical site rated 8 out of 10. There is a prn prescription for 10 mg PO of oxycodone for pain greater than 6 out of 10 on the pain scale. Which action should the nurse take first?

*Verify clients name and date of birth. -the first step is to have the client verify name and date of birth.

What is a Vial?

*Vial- A glass or plastic container of parental medication with a self-sealing rubber stopper.

How to remove gloves properly?

*When removing gloves, the dominant hand is used to grasp the opposite glove near the cuff end on the outside exposed area. It is pulled off and inverted, with the contaminated area on the inside. The removed glove is held in the remaining gloved hand. Then, the fingers of the ungloved hand are slid between the remaining glove and the wrist and the glove is pulled off and inverted.

What is healing by Primary Intention?

*Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention.

What is healing by Secondary Intention?

*Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention.

Healing by Primary Intention-

*Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the wound are approximated and the risk of infection is lower when a wound heals in this manner.

A physician at a health care facility suggests the use of a metered-dose inhaler for an asthmatic client. Which describes the mechanism of a metered-dose inhaler?

*a canister containing medication that is released when the container is compressed. -A metered-dose inhaler is a canister that contains medication under pressure; the aerosolized drug is released when the container is compressed.

What is a Jackson-Pratt (JP) Drain?

*a closed-suction medical device that is commonly used as a post-operative drain for collecting bodily fluids from surgical sites also called a JP drain.

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?

*a surgical incision with sutured approximated edges.

Which clients would be considered at risk for skin alterations? Select all that apply.

*a teenager with multiple body piercings *a client receiving radiation therapy *a client with diabetes

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site?

*a transparent film -Transparent film dressings are semipermeable, waterproof, and adhesive, allowing visualization of the access site to aid assessment and protecting the site from microorganisms.

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate?

*administration of an antipsychotic agent to alter the client's behavior. -Chemical restraints are medications, such as an antipsychotic, that are used to manage a client's behavior or freedom of movement.

The nurse recognizes that assessment for sensory-perceptual alterations is a priority for which client?

*an 84-year-old male with four recent driving violations.

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

*an obese woman with a history of type 1 diabetes. -Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process.

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention?

*applying sterile dressings with normal saline over the protruding organs and tissue. -The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.

The nurse is administering an intramuscular injection to a client. Which action made by the nurse could assess whether the needle is in the client's blood vessel or not?

*aspirating for a blood return. -Aspirating for a blood return is correct, as this will determine if the needle is in the blood vessel.

A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:

*automobile accidents. -Adolescents are prone to injuries related to activities that involve high risk, such as driving. Adolescents tend to be impulsive and take unnecessary risks as a result of peer pressure.

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

*corticosteroids -Clients who are taking corticosteroids or require postoperative radiation therapy are at high risk for delayed healing and wound complications. **Corticosteroids decrease the inflammatory process, which may delay healing.

A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should:

*fill out an incident report, with the goal of preventing a similar event in the future.

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider?

*foul-smelling drainage that is grayish in color. -Purulent drainage is frequently foul-smelling and may vary in color; such drainage is associated with infection and should be reported to the health care provider.

A student nurse is performing hand washing in the clinical setting. Which observation would require the nursing instructor to intervene?

*has manicured nails that are 1-in. (2.5-cm) long. -Fingernails should be less than ¼-in. (0.625-cm) long.

When educating families on fire safety, it is important to:

*have a meeting place outside the home.

The nurse is preparing to administer a tuberculin test. Which route will the nurse select to administer this injection?

*intradermal-is injecting the drug between the layers of the skin.

A nurse is using the Z-track technique to administer an injection to a client. Which injection route utilizes the Z-track technique?

*intramuscular

The nurse is caring for a client with a yeast infection. Which medication does the nurse anticipate will be prescribed?

*miconazole- The nurse anticipates that miconazole, a vaginal cream, will be prescribed for a yeast infection.

When administering heparin subcutaneously, the nurse should?

*never aspirate.

A client comes to the emergency department reporting becoming very ill after consuming shrimp and lobster. How will the nurse document this condition?

*noncommunicable disease. -A noncommunicable disease is caused by food or environmental toxin.

Which action describes buccal (Cheek) medication administration?

*placing a medication underneath the upper lip or in the side of the mouth. -Buccal medication is not chewed, swallowed, or placed under the tongue.

A nurse is developing a plan of care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the plan to prevent the development of pressure injuries? Select all that apply.

*provide incontinent care every 2 hours and as needed *turn the client every 2 hours when the client is in bed *encourage the client to take fluids every 2 hours

What would be considered a "right" of drug administration? Select all that apply.

*right drug *right documentation *right dose *right client

The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely?

*second degree or partial thickness.

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this?

*secondary intention- Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base.

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage type should the nurse document?

*serosanguineous- Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink.

The nurse is preparing to administer nasal medication via a dropper to a client with severe congestion. Into which position will the nurse place the client?

*supine -To best facilitate instillation of nasal medication via a dropper, and to ensure that the drug is administered into the place where its effects are desired, the nurse will place the client in supine position.

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail to prevent this behavior, and chemical restraints fail, which treatment does the nurse anticipate will be ordered?

*temporary application of devices that reduce the client's ability to move arms.

A new mother is asking the nurse about care of her baby's skin. The nurse should instruct the mother:

*to apply sunscreen when exposed to ultraviolet rays.

What is the best explanation from the nurse as to why a client must return to the unit in 48 hours after having a tuberculin skin test intradermal?

*to determine the extent to which the client responded to the drugs.

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?

*transparent -The nurse should use a transparent dressing to cover the IV insertion site, because such dressings allow the nurse to assess a wound without removing the dressing.

The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room?

*transparent- Transparent dressings are used to protect intravenous insertion sites.

A nurse is caring for a client undergoing IV therapy. The nurse knows that intravenous administration of medication is appropriate in which situation?

*when the client has disorders that affect the absorption of medications. -Intravenous administration may be chosen when clients have disorders, such as severe burns, that affect the absorption and metabolism of medications. IV therapy is also used in an emergency when a quick response is needed.

The patient has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as:

*within normal limits- A normal white blood cell count is 5,000 to 10,000 cells/mm3.

Several family members are visiting a client with an antibiotic-resistant infection who has been placed on contact precautions. When the nurse teaches the visitors about wearing gloves and gowns, a family member states, "I don't want to wear those. I can't catch anything just by holding my loved one's hand." What is the best response to educate the family about infection transmission?

-"These barriers help prevent the transmission of infection to you or other people." *Contact precautions block transmission of pathogens by direct or indirect contact Wearing a gown and gloves decreases the chance of the contaminating organism to be spread to the visitors via hands or clothing or even to others the visitors may come in contact with.

A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client?

-Fungi. *Ringworm is caused by a fungal infection. Fungi include yeasts and molds, which cause infections in the skin, mucous membranes, hair, and nails.

The nurse working with the hospital's infection control team is attempting to decrease the transmission of healthcare-associated pathogens. Which intervention will be most effective?

-Incentivizing health care workers to utilize hand hygiene. *Most healthcare-associated pathogens are transmitted via the contaminated hands of health care workers. Therefore, the most effective strategies for decreasing transmission are those that educate or encourage health care workers to utilize effective hand hygiene.

Unbeknownst to him, a nursing student has inhaled droplets containing common cold viruses and is soon to develop a cold himself. Place the following stages of infection in the sequence in which they will occur.

-Incubation period -Prodromal stage -Full stage of illness -Convalescent period

A student nurse is attending a clinical rotation in the perioperative department and will be allowed to scrub in to observe. What observation made by the clinical instructor requires intervention before the student is allowed to attend the rotation? Select all that apply.

1. rings on finger 2. artificial nails with intact clear nail polish 3. red nail polish *Artificial nails and nail polish are never appropriate and may introduce infection into a surgical wound. Nail polish may chip and enter into surgical wounds. Rings should be removed because they are a source of contamination from bacteria and other pathogens.

Which client presents the most significant risk factors for the development of Clostridium difficile infection?

An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis

What is Survival adaptation?

An example of adaptation for survival is the development of antibiotic-resistant bacterial strains of Staphylococcus aureus, Enterococcus faecalis, E. faecium, and Streptococcus pneumoniae.

Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora?

Escherichia coli in the intestinal tract

A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique?

Hold sterile objects above waist level to prevent inadvertent contamination. *Holding a sterile object above waist level ensures the object is kept in sight and prevents accidental contamination.

What does Opportunistic Infection mean?

Opportunistic infections (OIs) are infections that occur more often or are more severe in people with weakened immune systems than in people with healthy immune systems. People with weakened immune systems include people living with HIV. OIs are caused by a variety of germs (viruses, bacteria, fungi, and parasites). OI-causing germs spread in a variety of ways, for example in the air, in body fluids, or in contaminated food or water. Here are examples of some of the most common OIs in people with HIV in the United States: Herpes simplex virus (HSV) infection—a viral infection that can cause painful cold sores in or around the mouth, or painful ulcers on or around the genitals or anus -Salmonella infection—a bacterial infection that affects the intestines (the gut) -Candidiasis (or thrush)—a fungal infection of the mouth, bronchi, trachea, lungs, esophagus, or vagina -Toxoplasmosis—a parasitic infection that can affect the brain

The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. What technique does the nurse use?

Pour the liquid into a sterile container within the sterile field.

The nurse planning to insert an indwelling urinary catheter into a client should utilize which technique?

Surgical asepsis- Surgical asepsis, also known as sterile technique, is utilized to keep objects and areas free from microorganisms when performing surgery and procedures such as insertion of an indwelling urinary catheter or IV catheter.

The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection?

an 80-year-old woman *Age, race, sex, and heredity all influence susceptibility to infection. Neonates and older adults tend to be most vulnerable to infection, so the 80-year-old woman is the client most at risk for infection. A neonate is defined as a child less than 4 weeks of age. An adolescent is a child aged 9 to 12 years. A toddler is a child who is 12 to 36 months or 1 to 3 years of age.

For which client would the use of standard precautions alone be appropriate?

an incontinent client in a nursing home who has diarrhea

The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection?

an older adult client with a history of heart failure

The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating, "You did not wash your hands!" Which response by the nurse is most appropriate?

"Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin."

The parent of a pediatric client tells the nurse, "I do not believe in vaccinations." What is the appropriate nursing response?

"Help me understand your perspective about vaccinating."

A pediatric client's caregiver states, "I will never give my child vaccinations." What is the priority nursing response?

"Help me understand your thoughts about vaccinations."

A family member with a mild upper respiratory infection comes to visit a client in a long-term care facility. The nurse takes the opportunity to teach the family member about preventing the spread of the cold. What response by the family member indicates that the nurse's teaching was successful?

"I will obtain a mask from the staff and wash my hands before touching my family member."

The nurse reminds the visitor of a client with an antibiotic-resistant infection that gloves are necessary. The visitor states, "I need to directly hold my loved one's hand without a barrier." What essential information does the nurse need to explain to the visitor to prevent transmission of the organism?

"The glove is an important barrier in preventing the transmission of your loved-one's antibiotic-resistant infection to you or other people you come in contact with."

A pregnant woman with a history of genital herpes infection who is near term asks the nurse why she must have a cesarean section when she has not had an outbreak in a "long time". The nurse responds:

"You may have infection in your birth canal that you are unaware of." *Viral diseases such as chickenpox or herpes simplex, acquired from the birth canal or from an infected sibling, can cause severe widespread disease.

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?

*"Very little scar tissue will form."

How many PT identifiers should you use?

*2 1. asking patient name and DOB 2. comparing to id bracelet

What is a Penrose Drain?

*A Penrose drain is an open drainage system that exits the skin through a stab wound. The purpose a Penrose drain is to provide a sinus tract for drainage.

What does teratogenic mean?

*A teratogen is an agent that can disturb the development of the embryo or fetus. (Birth defects).

What is an ampoule?

*Ampoule- A sealed glass drug container that must be broken to withdraw the medication.

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?

*Avoid unattended baths for the toddler.

What does DEHISCENCE mean?

*Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed.

A nurse is administering a hepatitis B shot intramuscularly. What would be the appropriate site for administration?

*Deltoid

The nurse is assessing a client with diabetes who has poor vision. Which feature of the insulin pen makes it beneficial for this client?

*Each unit of insulin is accompanied by a clicking sound in the pen.

What does half-life mean?

*Half-life is the amount of time it takes for 50%of the blood concentration of a drug to be eliminated.

The nurse has given a client an injection. How will the nurse prevent an accidental needle stick?

*Immediately activate the safety needle and place the syringe and needle into a Sharps container.

A 77-year-old client has experienced an ischemic stroke and is now dependent for all activities of daily living. What components of nursing care will the nurse initiate to prevent skin breakdown?

*Implement a 2-hour repositioning schedule.

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors?

*Local capillary pressure must be lower than external pressure.

What does the acronym RACE stand for?

*RACE stands for Rescue - Alarm - Contain - Extinguish.

What are common sites used for INTRADERMAL INJECTIONS?

*Sites commonly used for intradermal injections are the inner surface of the forearm and the upper back, under the scapula.

Subcutaneous Injection

*Subcutaneous Tissue (Fat) under the skin. Either at a 90* angle- if pinching 2in of skin. 45* angle if pinching 1in of skin.

A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client?

*Subcutaneous tissue- The subcutaneous tissue is the skin layer that is responsible for storing fat for energy.

Muscle Layer-

*The muscle layer moves the skeleton.

What is a Ventrogluteal Site?

*The ventrogluteal site is a large muscular injection site that provides a location with the capacity for depositing and absorbing the drug.

The school nurse is educating 7th grade children about safety. Which recommendation is most appropriate for this age group?

*Use protective sporting equipment.

To which client would the nurse be most likely to administer a p.r.n. medication?

*a client who is reporting pain near the surgical site.

What are Antineoplastic Drugs?

*chemotherapy drugs- Antineoplastic drugs are absorbed through the skin and should always be handled with caution.

Toddlers are vulnerable to injuries related to?

*falling from staircases is a common injury among toddlers

Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning?

*keeping medications in clearly labeled containers

The nurse is using aseptic technique to insert an indwelling urinary catheter. Which technique made by the nurse is correct?

*keeping sterile field above waist level.

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

*removing dead or infected tissue to promote wound healing.

noncommunicable disease

-A noncommunicable disease is caused by food or environmental toxin.

What does Causative mean?

-a biologic pathogen that causes a disease, such as a virus.

What are the 11 Patient RIGHTS of Medication admin?

1. Patient 2. Medication 3. Dose 4. Route 5. Time 6. Reason 7. Assessment 8. Documentation 9. Education 10. Response 11. Refusal

Which practice is a correct application of infection control practices?

A nurse performs hand washing each time the nurse removes a pair of gloves.

A nurse's gloves became soiled while providing morning care for a client. Which action best demonstrates that the nurse applied principles of infection control?

After removing the glove on the nondominant hand, hold the removed glove in the remaining gloved hand.

The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse?

Apply a nonparticulate (N-95) respirator when entering the room.

A nurse has finished providing care for a client who is on contact precautions. When removing the protective gown, the nurse should take which action?

Avoid touching the outer surfaces of the gown.

The nurse is preparing to don (to put on) a gown to care for a client requiring contact precautions. When should the nurse don the gown?

Before entering the client's room.

The nurse is inserting an indwelling catheter. What steps will the nurse distinguish as priority in preventing an infection?

Create an area for sterile field and opening packages

Which nursing action carries the greatest likelihood of contributing to the spread of vancomycin-resistant enterococci (VRE)?

Emptying the Foley catheter bag of a client with VRE and then helping the client in the next bed transfer to a chair without washing hands between contact.

The nurse is providing care for a client with varicella. What action should the nurse perform?

Ensure the client is housed in a negative pressure room.

An experienced nurse is teaching a student nurse about the proper use of hand hygiene. Which guideline should the nurse provide to the student?

Hand hygiene is needed after contact with objects near the client.

A nurse has been exposed to urine while changing the linens of a client's bed. Which guideline is followed for performing hand hygiene after this client encounter?

Keep hands lower than elbows to allow water to flow toward fingertips.

What is Medical asepsis?

Medical asepsis reduces the number and transfer of pathogens. Universal precautions and contact precautions help to decrease the risk of transmitting infection.

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which intervention should the nurse implement to ensure electrical safety?

Obtain a three-prong grounded plug adapter.

Following a demonstration to a family member on how to insert a straight catheter, the nurse instructs the family member to remove the gloves by inverting one glove into the other. Which step would the nurse instruct the family member to do next?

Perform hand hygiene

The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate?

Place a surgical mask on the client and transport to the CT department at the specified time.

What is an accurate guideline for the use of PPE?

Replace gloves if they are visibly soiled.

The nurse manager for a long-term facility notes an increase in infection rates among residents. Which would be the best to implement?

Review the current infection control protocols.

What is Surgical Asepsis?

Surgical asepsis (sterile technique)- is utilized to keep objects and areas free from microorganisms when performing surgery and procedures such as insertion of an indwelling urinary catheter or IV catheter.

A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure?

Surgical asepsis technique

A client has tested positive for methicillin-resistant Staphylococcus aureus after being swabbed on admission to the hospital. Bacterial resistance to antibiotics is an example of:

Survival adaptation

A client has a diagnosis of HIV and has been admitted to the hospital with an opportunistic infection that originated with the client's normal flora. Why did this client most likely become ill from his resident microorganisms?

The client's immune system became further weakened

A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety?

The nurse places the client in a private room with monitored negative air pressure.

A nurse is applying the principles of Standard and Contact Precautions in the care of a hospital client. Which action violates these principles?

The nurse removes her gown and then removes her gloves.

The nurse performs hand hygiene using soap and water before and after providing client care. Which nursing action is performed correctly according to the procedure?

The nurse washes at least 1 in (2.5 cm) above the area of contamination if present. *the nurse must wash at last 1 in (2.5 cm) above the area of contamination to properly performed hand hygiene. The nurse should use warm to hot water to wash hands.

A nurse is in charge of care for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which guideline is accurate for using transmission-based precautions when caring for this client?

Wear gloves whenever entering the client's room.

The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based hand rub is appropriate in which situation?

When hands are visibly soiled

In which situation is an alcohol-based rub an inappropriate option for hand hygiene?

When the nurse's hands are visibly soiled

Surgical asepsis is defined as:

absence of all microorganisms.

The nurse and a colleague have admitted a client who is on contact precautions. The nurse and colleague are removing their personal protective equipment and the nurse sees the colleague perform the pictured action. What is the nurse's most appropriate response?

encourage the colleague to remove the glove by grasping the cuff

Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile?

gown and gloves

A nurse is working with a 55-year-old woman diagnosed with human immunodeficiency virus (HIV). This nurse has another client that day who has an upper respiratory infection. What is the most important thing the nurse can do to prevent the client with HIV from acquiring the upper respiratory infection?

perform hand hygiene before and after entering the client's room

The nurse notices a student preparing to enter the room of a client with pulmonary tuberculosis with only gloves on. What is the appropriate nursing intervention?

remind the student that a fitted N95 respirator is required

The nurse manager is developing a plan to decrease the transmission of health care associated infections. What would be the best to implement?

staff education on utilizing hand hygiene

The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection?

the client who is 48-hours postsurgical procedure

Which is not appropriate regarding the use of gowns as PPE?

use of one gown per person per shift.

Which nursing action demonstrates safe injection practice?

use sterile single-use disposable syringes for each injection

A nurse has sustained a puncture wound on the hand from a scalpel blade that was left on a used procedure tray. What is the first action by the nurse?

wash the area with soap and water

Which care intervention should the nurse anticipate when providing care to a client admitted with a possible diagnosis of tuberculosis (TB)?

wearing a particulate respirator for all client care and interaction

A client is admitted to the hospital with tuberculosis. Which statement by the nurse explains how to reduce the risk of transmission to others?

"All visitors who enter the room must wear special masks."

The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate?

"Dehiscence is when a wound has partial or total separation of the wound layers."

A client is diagnosed with hepatitis C. What statement made by the client indicates that further education is required regarding the transmission of the virus?

"I probably got the virus when I sat on the toilet seat in a dirty bathroom." -The virus cannot be contracted or spread through a toilet seat.

The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug?

"This antibiotic is the best choice since the causative organism is not known." *Broad spectrum antibiotics are appropriate when the client is symptomatic and the causative bacteria is not yet known. These agents produce the best chance of effectiveness.

Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age?

*"Always provide close supervision for young children when they are in or around pools and bathtubs."

The nurse is teaching a nursing student regarding safety of chemotherapeutic medication. Which statement by the nurse is correct?

*"Antineoplastic drugs can be absorbed through the skin."

During a teaching session on self-administration of insulin, the client asks the nurse why it is necessary to bunch the skin before inserting the needle. What is the nurse's best response?

*"Bunching your skin facilitates the placement of the needle in the subcutaneous tissue."

Factors Affecting absorption?

*6 1-Route of admin 2-lipid solubility 3-pH 4-blood flow 5-local conditions at site of admin 6-drug dosage

How often should infected wound dressings be changed?

*Infected wounds may require dressing changes every 12 to 24 hours.

What type of PPE should be worn w/ a PT who has Pneumonia?

*Pneumonia requires DROPLET precautions, including a gown, mask, and gloves.

What is the primary role of the nurse in the care of clients who experience domestic violence?

*Providing prompt recognition of the potential or actual threat to safety.

Which client would most likely require placement of an implantable port?

*a 58-year-old woman with stage 3 breast cancer requiring weekly chemotherapy

Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)? Select all that apply.

*airborne precautions *droplet precautions *contact precautions The CDC has three general precautions: contact, droplet, and airborne.

Which level of health care provider may make the decision to apply physical restraints to a client?

*nurse practitioner

Drugs known to cause birth defects are called?

*teratogenic.

What does Convalescent mean?

-A person who is recovering from an illness or operation.

How is Hepatitis C transmitted?

-There are several ways for a client to either transmit the virus or to contract the virus including sharing needles, using unsterilized tattoo needles, and receiving blood transfusions prior to 1992.

The nurse is caring for a client who became very ill after ingesting seafood. How will the nurse document this condition?

-noncommunicable disease. A noncommunicable disease is caused by food or environmental toxin.

A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection?

-surgical asepsis *Clients are at risk for health care-associated infections when the health care staff does not follow safety guidelines. Medical and surgical asepsis are the primary safety interventions for preventing disease in the health care environment.

In which order should the following steps for putting the first hand into a sterile glove be performed?

1. Place the sterile glove package on a clean, dry surface at or above your waist. 2. Open the outside wrapper by carefully peeling the top layer back and remove inner package, handling only the outside of it. 3. Place the inner package on the work surface with the side labeled "cuff end" closest to the body. 4. Carefully open the inner package. Fold open the top flap, then the bottom and sides. 5. With the thumb and forefinger of the nondominant hand, grasp the folded cuff of the glove for the dominant hand, touching only the exposed inside of the glove. 6. Keeping the hands above the waistline, lift and hold the glove up and off the inner package with fingers down. 7. Carefully insert dominant hand palm up into the glove and pull it on.

Admin of Parenteral Medications

1. Subcutaneous injection- subcutaneous tissue 2. Intramuscular Injection- Muscle tissue 3. Intradermal Injection- Corium (under epidermis) 4. Intravenous Injection- Vein 5. Intraarterial Injection- Artery 6. Intracardial Injection- Heart Tissue 7. Intraperitoneal Injection- Peritoneal Cavity 8. Intraspinal Injection- Spinal canal 9- Intraosseous Injection- Bone

The acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in this acronym stands for which of the following?

Activate the fire alarm and notify the appropriate person.

When preparing a sterile field, the nurse notes that the bottle of sterile saline was opened 48 hours ago and is half full. What action does the nurse take to ensure that the saline used is sterile?

Discard the bottle and get a new one because the saline has expired.

The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate?

Disinfect it with alcohol swabs.

The client is an employee on the medical unit at the local children's hospital. The nurse is an occupational health nurse educating the client on various routes of exposure. The nurse knows that as a hospital employee, the client is most susceptible to infection by what mode of transmission?

contact

When a nurse picks up a client's contaminated tissue without gloves and fails to wash the hands sufficiently, the nurse provides for the client's organisms to be spread by which type of transmission?

contact

The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan?

hand washing

The nurse observes an unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene?

removes gloves and walks out of the room

Standard precautions apply to blood; all body fluids, secretions, and excretions; and intact and nonintact skin and mucous membranes.

true

A nurse is caring for a 55-year-old postoperative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first?

urinary catheter