Elsevier Adaptive Quizzing: Safety and Infection Control

When caring for a client who is receiving enteral feedings, the nurse would take which measure to prevent aspiration? 1. Elevate the head of the bed between 30 to 45 degrees. 2. Decrease flow rate at night. 3. Check for residual daily. 4. Irrigate regularly with warm tap water.

Answer: 1. Elevate the head of the bed between 30 to 45 degrees. Rationale: To prevent aspiration, the nurse would keep the head of the bed elevated between 30 to 45 degrees. Elevating the head any higher causes increased sacral pressure and increases the risk of skin breakdown. Decreasing flow rate, checking for residual, and irrigating regularly will not prevent aspiration.

Which threats include the term 'NBC' lead to the implementation of improved emergency medical services (EMS) and hospital safety programs? Select all that apply. One, some, or all responses may be correct. 1. Nuclear 2. Biological 3. Botulism 4. Chemical 5. Nipah virus

Answer: 1. Nuclear 2. Biological 4. Chemical Rationale: The term 'NBC' was coined to describe nuclear, biological, and chemical threats. In response, EMS agencies and hospitals improved safety by upgrading their decontamination facilities, equipment, and all levels of personal protective equipment to better protect staff. Botulism and Nipah virus are two specific examples of biological threats.

Which element would the nurse focus on when teaching crutch-walking to a client who has a casted leg fracture? 1. Establishing a schedule for pain medication 2. Maintaining a fixed schedule of daily activities 3. Modifying the home environment to prevent accidents 4. Understanding that a more sedentary lifestyle is necessary

Answer: 3. Modifying the home environment to prevent accidents Rationale: Modifications in the home may be needed to permit safe use of crutches. Pain medications should not be required on a regular basis. The client may vary the schedule of activities based on abilities and responses to activities. The client does not have to be sedentary; crutches are used for ambulation.

Which information would the nurse provide a client with a new colostomy about managing the appliance? 1. Use stoma powder for fungal rashes. 2. Wash peristomal area with soap first. 3. Measure stoma once a month for size. 4. Cut opening 1/8- to 1/16-inch larger than stoma.

Answer: 4. Cut opening 1/8- to 1/16-inch larger than stoma. Rationale: The first 6 to 8 weeks after surgery as inflammation subsides, the stoma will shrink in size. Therefore, it is important to measure the stoma once a week and cut the opening 1/8- to 1/16-inch larger than the stoma so the wafer does not cut into the stoma. Antifungal cream or powder is used for fungal rashes. Soap should not be used on the peristomal area to prevent drying, which can lead to infection.

Which intervention would the nurse include in the plan of care for a client admitted with herpes zoster? Select all that apply. One, some, or all responses may be correct. 1. Acyclovir 2. Silvadene 3. Gabapentin 4. Wet compresses 5. Contact isolation

Answer: 1. Acyclovir 2. Silvadene 3. Gabapentin 4. Wet compresses 5. Contact isolation Rationale: A client with herpes zoster would receive antiviral medications such acyclovir. Silvadene can be applied to open vesicles. Gabapentin can be used to treat the nerve pain associated with herpes zoster. Wet compresses can be applied to the vesicles to relieve discomfort. Herpes zoster is highly contagious, and the client would be placed in contact isolation precautions.

Which medication is safe to take during pregnancy? Select all that apply. One, some, or all responses may be correct. 1. Metronidazole 2. Aspirin 3. Codeine 4. Acetaminophen 5. Diphenhydramine HCl

Answer: 4. Acetaminophen Rationale: Acetaminophen may be taken safely during all stages of pregnancy. Metronidazole should not be used during the first trimester of pregnancy. Salicylates like aspirin, codeine, and antihistamines like diphenhydramine HCl should be avoided throughout pregnancy.

The registered nurse (RN) is giving home care instructions to a client who was treated for injuries due to a fall. Which statement made by the client indicates a need for additional instruction? 1. 'I should walk on soft scatter rugs at home.' 2. 'I should drink 3000 mL of water every day.' 3. 'I should eat fruits and vegetables six times a day.' 4. 'I should exercise the joints above and below the cast daily.'

Answer: 1. 'I should walk on soft scatter rugs at home.' Rationale: A client with injuries due to a fall must avoid having throw or scattered rugs at home to reduce the incidence of falls. The registered nurse (RN) would encourage the client to drink 3000 mL of water per day to promote optimal bladder and bowel function. The client would eat six small meals with foods rich in fiber, such as fruits and vegetables, to prevent constipation. The RN has to encourage the client to perform exercise above and below the cast daily for a speedy recovery.

Which statement indicates the patient understands the origin of hepatitis C? 1. 'You can catch it while you're getting a tattoo.' 2. 'You're more likely to get it in crowded living conditions.' 3. 'The disease is passed from person to person by causal contact.' 4. 'People working at restaurants can give it to you if they don't wash their hands.'

Answer: 1. 'You can catch it while you're getting a tattoo.' Rationale: The hepatitis C virus (HCV) is a blood-borne pathogen; it can be acquired during the application of a tattoo with equipment that contaminated with the hepatitis C virus. Hepatitis C is not transmitted by close contact in crowded spaces; HCV is a blood-borne pathogen. HCV is not transmitted by casual contact; it is a blood-borne pathogen. The fecal-oral route of transmission is associated with hepatitis A, not hepatitis C.

A client reporting a recent bee sting presents with localized redness, swelling, intense localized pain, and itching. Which action would the nurse implement? 1. Applying cold compresses to the affected area 2. Ensuring the client keeps the skin clean and dry 3. Monitoring for neurological and cardiac symptoms 4. Advising the client to launder all clothes with bleach

Answer: 1. Applying cold compresses to the affected area Rationale: A client with a bee sting may have localized redness, swelling, pain, and itching due to an allergic reaction. The nurse would apply cold compresses to the affected area to reduce the pain and edema at the sting site. A client with Candida albicans infection should keep his or her skin clean and dry to prevent further fungal infections. A client with a Borrelia burgdorferi infection may suffer from cardiac, arthritic, and neurological manifestations, which requires monitoring by the nurse. Direct contact may transmit a Sarcoptes scabiei infection; the should should make sure the client bleaches his or her clothes to prevent the transmission of the infection.

The nurse should take which infection control measures when caring for a client admitted with a tentative diagnosis of infectious pulmonary tuberculosis (TB)? 1. Don an N95 respirator mask before entering the room. 2. Put on a permeable gown each time before entering the room. 3. Implement contact precautions and post appropriate signage. 4. After finishing with client care, remove the gown first and then remove the gloves.

Answer: 1. Don an N95 respirator mask before entering the room. Rationale: An N95 respirator mask is unique to airborne precautions and for clients with a diagnosis such as tuberculosis, varicella, or measles. The gown needs to be nonpermeable to be protective. Airborne precautions, not contact precautions, are required. When finished with care, gloves would be removed first because they are the most contaminated.

Who is responsible for triaging the victims of a multiple motor vehicle crash on a major interstate? 1. Emergency first responders 2. Nurses in the acute care areas 3. Nurses in the emergency department 4. Health care providers in the emergency department

Answer: 1. Emergency first responders Rationale: For a mass casualty incident, triaging will occur in the field or at the site of the incident. In this case, the emergency first responders will triage the victims of the crash. Nurses in the acute care areas may or may not have victims admitted for care. The victims should be triaged before arriving in the emergency department, so it would be incorrect to expect the nurses and health care providers in the emergency department to perform triage.

Which nursing action is appropriate when terminating exposure for a toddler who presents to the emergency department (ED) after eating a lily? 1. Emptying the mouth 2. Monitoring vital signs 3. Questioning the parents 4. Placing in a side-lying position

Answer: 1. Emptying the mouth Rationale: To terminate exposure, the nurse would empty the toddler's mouth of any plant remnants. Monitoring vital signs is an assessment action. Questioning the parents helps identify the poisonous substance. Placing the child in a side-lying position is a nursing action that prevents further absorption or prevents aspiration with emesis.

In which position would the nurse place a client with a spinal cord injury experiencing autonomic dysreflexia? 1. High Fowler 2. Left side-lying 3. Right side-lying 4. Flat on the back

Answer: 1. High Fowler Rationale: A client experiencing autonomic dysreflexia would immediately be placed sitting up to lower blood pressure. Left side-lying, right side-lying, and flat-on-the-back positions would not lower blood pressure.

For which condition would an infant born with exstrophy of the bladder be at risk? 1. Infection 2. Dehydration 3. Urine retention 4. Intestinal obstruction

Answer: 1. Infection Rationale: The greatest problem facing this infant is infection of the bladder mucosa and excoriation of the surrounding tissue; meticulous hygiene is necessary both before and after surgery. Dehydration is not a problem, because fluid intake and the amount of urine output are not affected. Urine retention is not a problem, because the urine drains continuously. The congenital abnormality involves the genitourinary system, not the intestines.

To meet the criteria of ethical practice, which action would the nurse who witnessed the spouse of a client fall take? 1. Initiate an agency incident report. 2. Report the fall to the state (provincial) health department. 3. Write a brief description of the incident to be kept by the nurse manager. 4. Determine that no documentation is needed because the visitor is not a client in the hospital.

Answer: 1. Initiate an agency incident report. Rationale: Health care agencies document the occurrence of any event out of the ordinary that results in or has the potential to harm a client, employee, or visitor. Falls by visitors are not required to be reported to state (provincial) health departments. However, incident reports are required to be presented to accrediting agencies for review when an agency is in the process of being accredited. Writing a brief description of the incident to be kept by the nurse manager is not a requirement of ethical practice. However, the nurse who is involved in an incident or is a witness to an incident would write an accurate description of the event, along with the names of individuals involved. This documentation would be kept by the nurse at home. Lawsuits may take several years before they come to trial, and personal notes may help the nurse recall the event. The documentation must accurately contain the same elements included in the formal incident report. Taking no action is irresponsible. All events out of the ordinary that result in or have the potential to harm a visitor would be documented in an agency incident report.

Which plant, if ingested by a toddler, would necessitate further action by the nurse? 1. Lily 2. Rose 3. Coleus 4. Begonia

Answer: 1. Lily Rationale: If a toddler eats a lily, the nurse would tell the parents that the plant is poisonous and to proceed to the emergency department for further care. Rose, coleus, and begonia are not poisonous and would require no further action by the nurse.

Which emergency medical service agency offers service such as first aid stations and special-need shelters during a disaster or pandemic disease outbreak? 1. Medical Reserve Corps (MRC) 2. National Disaster Medical System (NDMS) 3. Disaster Medical Assistance Team (DMAT) 4. Federal Emergency Management Agency (FEMA)

Answer: 1. Medical Reserve Corps (MRC) Rationale: The MRC may help staff hospitals or community health settings that face shortages and provide first aid stations or special-need shelters. The NDMS manages mass fatalities, emergency animal care, and establishes fully functional field surgical facilities. A DMAT is a medial relief team deployed to a disaster area with enough medical equipment and supplies to sustain operations for 72 hours. FEMA provides Community Emergency Response Team (CERT) training so that people are better prepared for disasters and hazard situations in their own communities.

Arrange the events of an examination of a rape victim for a sexually transmitted infection in correct order. 1. Repetition of serological tests for syphilis and HIV infection 2. Serum sample for HIV infection, hepatitis B, and syphilis 3. Nucleic acid amplified testing for chlamydia and gonorrhea 4. Wet mount and culture or point-of-care testing of a vaginal swab specimen for trichomoniasis

Answer: 1. Nucleic acid amplified testing for chlamydia and gonorrhea 2. Wet mount and culture or point-of-care testing of a vaginal swab specimen for trichomoniasis 3. Serum sample for HIV infection, hepatitis B, and syphilis 4. Repetition of serological tests for syphilis and HIV infection Rationale: First, the sexual assault nurse would conduct nucleic acid amplified testing for chlamydia and gonorrhea. Next, the nurse would check for trichomoniasis via a wet mount and culture or point-of-care testing of a vaginal swab specimen. After this, a serum sample for HIV infection, hepatitis B, and syphilis should be conducted. Finally, serological tests for syphilis and HIV infection are repeated every 3 to 6 months after the assault.

To ensure client and visitor safety during transport of a client with influenza (H1N1) for a computed tomography, the nurse would take which precaution? 1. Place a surgical mask on the client. 2. Other than standard precautions, no additional precautions are needed. 3. Minimize close physical contact. 4. Cover the client's legs with a blanket.

Answer: 1. Place a surgical mask on the client. Rationale: Nurses would provide influenza clients with face masks to wear for source control and tissues to contain secretions when outside of their rooms. Special precautions such as face mask would be taken to decrease the risk of further outbreak. Minimizing close physical contact is not indicated. Covering the client with a blanket is for comfort and privacy, not because of a transmission precaution.

In Which order would clients receive care based on triage tag color? 1. Yellow 2. Red 3. Green 4. Black

Answer: 1. Red 2. Yellow 3. Green 4. Black Rationale: Clients with a red tag generally have life-threatening conditions involving airway obstruction and shock. Red-tagged clients should be seen immediately. Clients who are dead or expected to die are labeled with black tags, are classified as expectant, and are given the lowest priority. Green-tagged clients have minor injuries that can receive treatment within 2 hours and are classified as nonurgent. Clients with yellow tags have injuries or conditions that need treatment within 30 minutes to 2 hours and who can be treated after red-tagged clients.

Which intervention is most important in preventing hospital-acquired catheter-associated urinary tract infections (CAUTIs)? 1. Removing the catheter 2. Keeping the drainage bag off of the floor 3. Washing hands before and after assessing the catheter 4. Cleansing the urinary meatus with soap and water daily

Answer: 1. Removing the catheter Rationale: Research demonstrates that decreasing the use of indwelling urinary catheters is the most important intervention to prevent CAUTIs. Keeping the drainage bag off the floor, washing hands before and after assessing the catheter, and cleansing the urinary meatus daily with soap and water will help reduce infections; however, these are not the most important interventions to prevent CAUTIs.

Which action puts a client at risk for low back injury and pain? 1. Smoking tobacco 2. Regular swimming exercise 3. Vitamin D oral supplementation 4. Use of a footstool with prolonged sitting

Answer: 1. Smoking tobacco Rationale: Smoking is a risk factor for low back pain and injury because it causes constriction of blood flow. Regular swimming exercise helps strengthen the back. Vitamin D supplementation works with calcium to strengthen the musculoskeletal system. Prolonged sitting can be augmented with a foot stool and ergonomic chair to support the back.

Which client/patient education would the nurse include about a potential complication of mumps? 1. Sterility 2. Hypopituitarism 3. Decrease in libido 4. Decrease in androgens

Answer: 1. Sterility Rationale: Mumps can cause orchitis (inflammation of the testes) in males and oophoritis (inflammation of the ovaries) in females. Although rate, both conditions can render the postpubescent child sterile. Hypopituitarism, diminished libido, and decreased levels of androgens are not associated with mumps.

A client has been placing used insulin needs in a container sealed with heavy-duty tape. Where would the nurse tell the client to dispose of the container? 1. The local hazardous waste collection site 2. The regular household trash 3. The local health department for disposal 4. The Environmental Protection Agency (EPA) through the mail

Answer: 1. The local hazardous waste collection site Rationale: Each state (province) has its own waste management guidelines for proper disposal of sharps containers, as well as hazardous waste collection sites. Clients cannot place needles in the regular household trash because sharps are considered medical waste. The local health department does not collect sharps containers. Sharps containers are not mailed directly to the EPA.

Which is the minimum number of disaster drills the hospital disaster plan committee must plan and implement each year? 1. Two 2. Three 3. Four 4. Five

Answer: 1. Two Rationale: Although it is appropriate to have more than the minimum number of disaster drills each year, the minimum that must be implemented per The Joint Commission (TJC) requirements is twice per calendar year.

Which information would the nurse include in a community education session on decreasing the risk for musculoskeletal injuries? Select all that apply. One, some, or all responses may be correct. 1. Use of seatbelts 2. Obeying speed limits 3. Wearing safety equipment 4. Avoiding impaired vehicle use 5. Refraining from distracted driving

Answer: 1. Use of seatbelts 2. Obeying speed limits 3. Wearing safety equipment 4. Avoiding impaired vehicle use 5. Refraining from distracted driving Rationale: The nurse can provide several proactive steps for preventing musculoskeletal injuries at home, at work, and in the community. Community members should be advised to wear seatbelts, followed the speed limit, and refrain from distracted or impaired driving. Employees should be instructed to follow workplace safety procedures and practices including wearing safety equipment.

Which action would the nurse implement when providing care for a client with acquired immunodeficiency syndrome (AIDS)? 1. Use standard precautions. 2. Employ airborne precautions. 3. Plan interventions to limit direct contact. 4. Discourage long visits from family members.

Answer: 1. Use standard precautions. Rationale: The Centers for Disease Control and Prevention (Canada: Public Health Agency of Canada) states that standard precautions should be used for all clients; these precautions include wearing gloves, gown, mask, and goggles when there is risk for exposure to blood or body secretions. There is no indication that airborne precautions are necessary. Planning interventions to limit direct contact or discouraging long visits from family members will unnecessarily isolate the client.

Which behavior is an early sign of abusive personality? Select all that apply. One, some, or all responses may be correct. 1. Verbal abuse 2. Jealous, controlling 3. Enforces rigid sex roles 4. Hypersensitive, easily insulted 5. Isolates partner from family and friends 6. Makes others responsible for their feelings

Answer: 1. Verbal abuse 2. Jealous, controlling 3. Enforces rigid sex roles 4. Hypersensitive, easily insulted 5. Isolates partner from family and friends 6. Makes others responsible for their feelings Rationale: Abuser behavior has several characteristics. A typical abuser has poor emotional control, a superior attitude toward women, a history of substance abuse, high levels of jealousy and insecurity, and hypersensitivity. Other characteristics include making others responsible for their feelings and using threats, such as verbal abuse, punishment, and physical violence, to control another's behavior. Controlling may extend to enforcing rigid sex roles and isolating a partner from family and friends. Early recognition of the characteristics of potential violence allows for effective intervention.

Which would the nurse teach the parent of an infant who is at risk for infections? 1. 'You must avoid placing the infant in bright sunlight.' 2. 'Breast-feeding will provide protection against bacteria.' 3. 'Use soy-based infant formulas to help prevent infection.' 4. 'The infant will be less susceptible to infections later in life.'

Answer: 2. 'Breast-feeding will provide protection against bacteria.' Rationale: Breast milk contains immunoglobulin G (IgG) that protects the infant against many bacteria, such as Escherichia coli. The nurse instructs the parent to avoid placing the infant in bright sunlight for a long period of time to prevent burns, but not to prevent infections. Soy-based infant formulas are used only if the infant is allergic to lactose in the breast milk and are not used to prevent the risk for infections. Later, susceptibility would be dependent on multiple factors, including nutrition and exposure to infections.

A parent reports that his or her child just ate several multivitamins with iron. Which statement would the nurse say to the parent? 1. 'Give your child orange juice.' 2. 'Call the Poison Control Center.' 3. 'Iron-fortified multivitamins are safe for your child.' 4. 'Administer an emetic-syrup of ipecac, if you have it.'

Answer: 2. 'Call the Poison Control Center.' Rationale: The Poison Control Center will provide the best guidance for treatment of excess ingestion of a substance; enemas, lavage, or chelation therapy with deferoxamine, a heavy metal antagonist, may be recommended, depending on the amount ingested and the child's age and response. Orange juice will enhance absorption of the iron and will create a greater risk for toxicity. Iron is the most toxic substance in multivitamins. Although signs and symptoms may not be evident for several hours, treatment should be initiated for a problem develops. Emetics are not used for poisonings; they are not effective in removing the toxic substance and causing the child to vomit creates a risk for aspiration.

Which school-age children require close supervision when using a skateboard? Select all that apply. One, some, or all responses may be correct. 1. 5 year old 2. 6 year old 3. 7 year old 4. 8 year old 5. 9 year old

Answer: 2. 6 year old 3. 7 year old 4. 8 year old 5. 9 year old Rationale: School-age children who are 6 years, 7 years, 8 years, or 9 years all require close supervision when using a skateboard. The 5-year-old school-age client should not be allowed to ride a skateboard due to the high risk for injury.

The nurse educator of a college health course is discussing tattoos with the class. Which type of hepatitis associated with tattoos would the nurse include in the teaching plan? 1. Hepatitis A 2. Hepatitis C 3. Hepatitis D 4. Hepatitis E

Answer: 2. Hepatitis C Rationale: Hepatitis C is a blood-borne pathogen that can be transmitted via contaminated tattoo needles. Hepatitis A is not a blood-borne pathogen; it is spread through contaminated food or water. Although hepatitis D is a blood-borne pathogen, it can be produced only when the hepatitis B virus is present. Also, hepatitis D is not the main virus associated with contaminated tattoo needles. Hepatitis E is believed to be transmitted via the fecal-oral route; it is spread though contaminated food or water.

Which infection would the nurse identify as requiring a client to be placed on droplet precautions? 1. Human immunodeficiency virus (HIV) 2. Influenza 3. Tuberculosis (TB) 4. Methicillin-resistant Staphylococcus aureus (MRSA)

Answer: 2. Influenza Rationale: Clients with influenza will be placed on droplet precautions because the infection can be spread by talking or sneezing. HIV-positive clients will be instructed to use barrier protection with any kind of sexual contact to prevent spread of the virus. Clients with TB will be placed an airborne transmission precautions. Clients with MRSA would require contact precautions

Identify the role of plasma cells in the antigen-antibody response. 1. Makes an antigen harmless without destroying it 2. Produces antibodies against the sensitizing antigen 3. Produces antibodies after an exposure to a known antigen 4. Clumps antibody-antigens linkages together to form immune complexes

Answer: 2. Produces antibodies against the sensitizing antigen Rationale: In the antigen-antibody response, once the B cell is sensitized, it divides and forms a plasma cell, which produces antibodies against the sensitizing antigen. Inactivation or neutralization is the process of making an antigen harmless without destroying it. Memory cells produce antibodies after the next exposure to an antigen that is recognized by the body. Agglutination is the clumping of antigens linked with antibodies, forming immune complexes.

Which adolescent behavior increases the risk of injury? Select all that apply. One, some, or all responses may be correct. 1. Poor diet 2. Substance abuse 3. Unprotected sex 4. Sedentary lifestyle 5. increased screen time

Answer: 2. Substance abuse 3. Unprotected sex Rationale: Behaviors that increase an adolescent's risk for injury include substance abuse and unprotected sexual intercourse. Poor diet, sedentary lifestyle, and increased screen time increase the risk for obesity, not injury.

In light of a nurse hearing a depressed client telling another client, 'I'll be feeling better soon,' which initial parameter would the nurse assess for in the depressed client? 1. Ability to sleep 2. Suicidal thinking 3. Current feelings of depression 4. Subjective ideas about treatment progress

Answer: 2. Suicidal thinking Rationale: The nurse would assess the client's suicidal thinking. The client's comment reflects the possibility of suicide; further assessment and protection of the client are necessary. Although sleep is affected by depression, the overheard comment does not make this a priority at this time. Although feelings of depression could be getting better and subjective ideas about treatment progress could be improving, neither is the priority at this time. These assessments can be addressed after the assessment for suicide.

A burn client is receiving the open method for wound treatment. Which information will the nurse explain to the client? 1. 'Bathing will not be permitted.' 2. 'Dressings will be changed daily.' 3. 'Personal protective equipment will be worn by staff.' 4. 'Room temperature will be kept below 72°F [22.2°C].'

Answer: 3. 'Personal protective equipment will be worn by staff.' Rationale: Personal protective equipment (disposable hates, masks, gowns, and gloves) are essential for the prevention of infection in clients with the open method of treatment. Hydrotherapy in a large tank tub may be used to clean burn wounds. Dressings are not used with the open method. Clients are more comfortable with a room temperature of 85°F (29.4°C).

By which age should an infant have had his or her first dental examination? 1. 3 months 2. 9 months 3. 12 months 4. 18 months

Answer: 3. 12 months Rationale: A child will have complete an initial dental visit by the age of 12 months. The initial examination should be completed by age 6 months or within 6 months of the first tooth erupting, which averages at around the age of 12 months.

Which would the nurse use to perform hand hygiene when caring for an immunocompromised client? 1. Soap 2. Betadine 3. Chlorhexidine 4. Alcohol-based hand sanitizer

Answer: 3. Chlorhexidine Rationale: Chlorhexidine will be used for hand hygiene when caring for immunocompromised clients because it decreases the risk of spreading infection. Cleansing hands with soap and alcohol-based hand sanitizers is not as effective at preventing the spread of infection. Betadine is not used for hand hygiene.

To which disaster triage class would the nurse infer a client with a green triage tag belongs? 1. Class I 2. Class II 3. Class III 4. Class IV

Answer: 3. Class III Rationale: The green disaster triage tag is issued to nonurgent or 'walking-wounded' clients who belong to class III. A red disaster triage tag is issued to clients who require immediate treatment and belong to class I. Clients with yellow and black tags belong to class II and IV respectively.

The nurse should seek clarification by the practitioner for which order? 1. Discharge in AM 2. Blood glucose monitoring ac and bedtime 3. Erythromycin 250mg TIW 4. Dalteparin 5000 international units Sub-Q BID

Answer: 3. Erythromycin 250mg TIW Rationale: TIW, indicating three times a week, is an unacceptable abbreviation. It may be mistaken for 'three times a day' or 'twice weekly.' The abbreviation AM for in the morning is an acceptable abbreviation. The word 'discharge' must be completely spelled out instead of just 'D/C' because this may be confused with 'discontinue.' The use of ac (before meals) is an acceptable abbreviation. Bedtime must be completely spelled out instead of 'hs' because 'hs' may be confused with 'half strength' or 'every hour.' The abbreviation Sub-Q, indicating subcutaneous route, is an acceptable abbreviation. BID, indicating twice a day, is an acceptable abbreviation. International units must be completely spelled out instead of 'IU' because it may be mistaken as a roman numeral four (IV).

Which clinical finding is associated with strabismus? 1. Bloodshot sclera 2. Excessive blinking 3. Frequent squinting 4. Continuous tearing

Answer: 3. Frequent squinting Rationale: Strabismus is a disorder in which the optic axes cannot be directed to the same object; this causes difficulty in focusing from one distance to the other. Eventually loss of vision in the eye will occur if the condition goes uncorrected. Squinting, a classic sign of strabismus, occurs because of the misalignment of the eyes. Bloodshot sclerae are associated with conjunctivitis, not strabismus. Blinking may indicated an affectation or nervous tic, not strabismus. Tearing may indicate blockage of the tear ducts, not strabismus.

Which method of delivering client care works well in disaster situations? 1. Team nursing 2. Primary nursing 3. Functional nursing 4. Total client care nursing

Answer: 3. Functional nursing Rationale: The functional method of delivering care works well in emergency and disaster situations. Each care provider knows the expectations of the assigned role and completes the tasks quickly and efficiently. Team nursing, primary nursing, and total client care nursing are not the ideal models for delivering client care during disaster situations.

Which color tag would the nurse use to triage a victim of a train derailment who is able to walk independently to the first aid station? 1. Red 2. Black 3. Green 4. Yellow

Answer: 3. Green Rationale: An emergency triage system uses colored tags to designate both the seriousness of the injury and the likelihood of survival. Green would be used for minor injuries such as the victim who is able to ambulate independently. Red indicates life-threatening injuries requiring immediate attention. Black indicates that the victim is expected to die. Yellow indicates urgent but not life-threatening injuries.

Which action would the nurse take to decrease the risk of transmission of vancomycin-resistant enterococci (VRE)? 1. Insert a urinary catheter. 2. Initiate droplet precautions. 3. Move the client to a private room. 4. Use a high-efficiency particulate air (HEPA) respirator during care.

Answer: 3. Move the client to a private room. Rationale: Contact precautions are used for client with known or suspected infections transmitted by direct contact or contact with items in the environment; therefore infectious clients must be placed in a private room. There is no need to insert an indwelling catheter, because this can increase the risk for additional infection. Droplet precautions are used for clients known or suspected to have infectious transmitted by the droplet route. These infections are caused by organisms in droplets that may travel 3 feet but are not suspended for long periods.

Which activity would the nurse manage complete during an emergency event when acting as the triage officer according to the Hospital Incident Command System (HICS)? Select all that apply. One, some, or all responses may be correct. 1. Facilitating the client movement through the system 2. Bringing in personnel and supply resources to meet needs 3. Rapidly evaluating each person who comes to the hospital 4. Identifying the need for and call in specialty providers 5. Determining numbers, acuity, and medical resource needs of clients arriving at the hospital

Answer: 3. Rapidly evaluating each person who comes to the hospital Rationale: In the role of triage officer, the nurse would rapidly evaluate each person who comes to the hospital, including those triaged in the field. The hospital incident commander facilitates client movement through the system and brings in personnel and resources to meet needs. The medical command physician identifies the need for and calls in needed specialty providers and determines the number, acuity, and medical resource needs of clients arriving at the hospital.

The nurse is caring for a client with bowel obstruction. Which assessment findings indicate the possible onset of peritonitis? Select all that apply. One, some, or all responses may be correct. 1. Diarrhea 2. Bradycardia 3. Rebound tenderness 4. Diminished bowel sounds 5. Rigid, boardlike abdomen

Answer: 3. Rebound tenderness 4. Diminished bowel sounds 5. Rigid, boardlike abdomen Rationale: Classic signs of peritonitis include abdominal rebound tenderness, diminished or absent bowel sounds, and a rigid, boardlike abdomen. The client will experience constipation, not diarrhea. The heart rate will be tachycardic.

The nurse is preparing to insert a nasogastric (NG) tube for a client to allow continuous suction. Which tube would the nurse select? 1. Levin 2. Dobhoff 3. Salem sump 4. Gastrostomy

Answer: 3. Salem sump Rationale: A Salem sump tube has a vent that prevents the suction from pulling at the gastrointestinal mucosa and should be used for clients requiring continuous suction. A Levin tube does not have a vent and should be used strictly for intermittent suction. A Dobhoff is a nasointestinal tube used for feeding, not suction. A gastrostomy tube is surgically placed for feeding.

Which should the nurse include when teaching a client with Clostridium difficile about decreasing the risk of transmission to family members? 1. Increase fluid intake 2. A high-fiber diet 3. Soap and water for hand washing 4. Wash hands with an alcohol-based hand sanitizer

Answer: 3. Soap and water for hand washing Rationale: Alcohol does not kill C. difficile spores. Use of soap and water is more efficacious than alcohol-based hand rubs. Increased fluids and increased fiber do not decrease the risk of transmission of C. difficile.

Why is an infection caused by Neisseria gonorrhoeae particularly troublesome for a female client? 1. The medication is expensive. 2. The infection is difficult to treat with antibiotics. 3. Symptoms are often overlooked. 4. Treatment has many adverse effects.

Answer: 3. Symptoms are often overlooked. Rationale: Many female clients who contract gonorrhea are asymptomatic or overlook the minor symptoms, making possible for the bacteria to remain a source of infection. There is no evidence to support the medication to treat the infection is expensive. The infection can be treated with one intramuscular injection of ceftriaxone. There is no evidence to support the medication to treat this infection has many adverse effects.

Which safety education would the nurse provide to the parent of a 3-month-old infant? 1. Remove small objects from the floor. 2. Cover electronic outlets with safety plugs. 3. Test the temperature of water before bathing. 4. Remove toxic substances from accessible areas.

Answer: 3. Test the temperature of water before bathing. Rationale: Excessively high temperatures can damage the delicate skin of an infant. Although infants are capable of putting small things in their mouths, a 3-month-old infant is not yet able to crawl and probably will not be placed on the floor. At 3 months of age, infants are not yet able to explore the environment to the point that electric outlets pose a problem. At 3 months of age, infants are still too small and have not yet developed motor capabilities to access hazardous substances.

The parents of a child diagnosed with hepatitis A express concern that other family members may contract hepatitis because they only have one bathroom. Which response would the nurse reply? 1. 'I suggest you buy an individual commode seat to use exclusively for your child's bathroom needs.' 2. 'Your child may use the bathroom, but you need to use disposable toilet seat covers.' 3. 'You will need to clean the bathroom from top to bottom every time a family member uses it.' 4. 'All family members, including your child, need to wash their hands after using the bathroom.'

Answer: 4. 'All family members, including your child, need to wash their hands after using the bathroom.' Rationale: Hepatitis A is spread via the fecal-oral route; transmission is prevented by proper hand washing. Buying a commode exclusively for the child's use is unnecessary; cleansing the toilet and washing the hands should control the transmission of microorganisms. Cleaning the bathroom 'from top to bottom' after each use is not feasible. The use of disposable toilet covers is inadequate to prevent the spread of microorganisms if the bathroom used by the child also is used by others. Hand washing by all family members must be part of the plan to prevent the spread of hepatitis to other family members.

Which statement made by the nurse requires correction with discussing registered nurse licensure in the United States with peers? 1. 'Candidates must pass the NCLEX-RN examination to become licensed in their state.' 2. 'The scope of practice for registered nurses is found in each state's Nurse Practice Act.' 3. 'The examination for RN licensure is exactly the same in every state in the United States.' 4. 'Passing the NCLEX-RN examination indicates maximal knowledge base for safe nursing practice.'

Answer: 4. 'Passing the NCLEX-RN examination indicates maximal knowledge base for safe nursing practice.' Rationale: The nurse requires correction when stating, 'Passing the NCLEX-RN examination indicates maximal knowledge base for safe nursing practice.' Passing the NCLEX-RN examination means the candidate possesses the minimum knowledge base for nurses to practice safely. Candidates must pass the NCLEX-RN examination to become licensed in their state. The scope of practice for registered nurses is found in each state's Nurse Practice Act. The examination for RN licensure is exactly the same in every state in the United States regardless of educational preparation (i.e., diploma nurse program, associate's degree in nursing program, baccalaureate degree in nursing program).

A client expresses concern regarding the lack of annual flu vaccines because of a supply and demand problem. Which response by the nurse is best? 1. 'This is an unfortunate situation, but there was such a limited supply available.' 2. ' There are many others who were unable to obtain a flue vaccine this month.' 3. 'The limited supply doesn't really matter because the vaccine is for one particular strain.' 4. 'There are other things you and your family can do to prevent the flu, such as hand washing.'

Answer: 4. 'There are other things you and your family can do to prevent the flu, such as hand washing.' Rationale: The statement 'There are other things you can do to prevent the flu, such as hand washing' is a teaching opportunity of which the nurse can take advantage and show the client the things that can be done to avoid infection. The response 'It's unfortunate, but there was such a limited supply available' is empathic, but it does not address the client's concern of vulnerability. The response 'There are many others who also were unable to get a flue vaccine' belittles the client for being concerned. The response 'I doesn't matter because the vaccine is for just one particular strain' may be true, but it belittles the client's concern.

Which team would be mobilized to manage the deceased at the earthquake zone where many people lost their lives? 1. Medical Reserve Corps (MRC) 2. National Veterinary Response Teams (NVRTs) 3. International Medical-Surgical Response Teams (IMSRTs) 4. Disaster Mortuary Operational Response Teams (DMORTs)

Answer: 4. Disaster Mortuary Operational Response Teams (DMORTs) Rationale: DMORTs are part of the DMAT. This team is specialized in managing mass fatalities during a disaster. The MRC helps staff hospitals or community health care settings that face shortages of nurses. They establish first aid stations and special-needs shelters in disasters. NVRTs provide emergency care to animals. IMSRTs provide fully functional field surgical facilities all over the world, wherever it is required.

How long would the nurse maintain isolation of a child with bacterial meningitis? 1. For 12 hours after admission 2. Until the cultures are negative 3. Until antibiotic therapy is completed 4. For 48 hours after antibiotic therapy begins

Answer: 4. For 48 hours after antibiotic therapy begins Rationale: Most child are no longer contagious after 24 to 48 hours of intravenous antibiotics. Twelve hours after admission is inadequate, even if antibiotics are started immediately. Keeping the child isolated until cultures are negative or antibiotic therapy is complete is an excessively long period and is unnecessary.

Which physiological factor increases the risk of falls for a toddler? 1. Poor muscle coordination 2. Underdeveloped proprioception 3. Underdeveloped skeletal muscles 4. Poorly developed depth perception

Answer: 4. Poorly developed depth perception Rationale: The toddler has poor depth perception, which increases the risk of falling. Poor muscle coordination, undeveloped proprioception, or underdeveloped skeletal muscles are not physiological findings in a toddler.

Two nurses are planning to help a client with one-sided weakness move up in bed. Which principle of body mechanics would the nurses observe? 1. Instruct the client to position one arm on each shoulder of the nurses. 2. Direct the client to extend the legs and remain still during the procedure. 3. Have both nurses shift their weight from the front leg to the back leg as they move the client up in bed. 4. Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client.

Answer: 4. Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client. Rationale: Positioning the nurses on either side of the bed with their feet apart, gathering the pull sheet close to the client, turning toward the head of the bed, and then moving the client places both nurses in a stable position in functional alignment, thereby minimizing stress on muscles, joints, ligaments, and tendons. The client should be instructed to fold the arms across the chest; this keeps the client's weight toward the center of the mass being moved and keeps the arms safe during the move up in the bed. The nurses would assist the client in flexing the knees and placing the feet flat on the bed; this enables the client to push the body upward using a major muscle group. The client's assistance to the best of his or her ability reduces physical stress on the nurses as they move the client up in bed. One the count of three, weight should be shifted from the back to the front leg, not the front to the back leg. This action generates movement in the direction in which the client is being moved.