Exam 1: Safety Practice Questions

Which phase of Stetler's model affirms priority in considering influential factors? 1. validation 2. preparation 3. translation and application 4. comparative evaluation and decision making

2 rationale: Preparation is phase I of Stetler's model, which affirms priority in considering influential factors. Validation is phase II of Stetler's model, which synthesizes findings and evaluates according to model criteria. Translation and application are phase IV of Stetler's model, which involves practical aspects of implementing the plan for translating research into practice. Comparative evaluation and decision making is phase III of Stetler's model, which involves making a decision about applicability by synthesizing findings.

After a modified radical mastectomy a client tells the nurse, "This diagnosis is as good as a death sentence, and I'd rather go now than suffer." What is the most important nursing intervention at this time? 1. recommending that the client admit herself to the psychiatric unit of the hospital 2. determining whether the client has experienced self-destructive suicidal thoughts 3. exploring the possibility of a vacation after hospitalization to reduce the client's stress level 4. encouraging the client to focus on the good things in her life to promote positive thinking

2 rationale: A client in obvious crisis who appears depressed, anxious, and desperate should be questioned regarding the presence of suicidal thoughts. Further assessment and exploration are needed before the client is encouraged to admit herself to a psychiatric facility. It is difficult for a client overwhelmed with problems to think positively. Running away from problems does not help solve them, nor will escaping bring lasting relief.

A father asks a nurse for strategies to convince his 5-year-old to wear a helmet while bicycling. What should the nurse suggest to the father? 1. you should forbid your child from riding a bicycle 2. you should wear your helmet while riding your bicycle 3. you should limit your child's bicycling to a defined area 4. you should tell your child about the risks associated with not wearing a helmet

2 rationale: The nurse should suggest the father to wear a helmet when he rides his bicycle. This sets a positive example for the child to wear his or her helmet. Restricting the child will interfere with the cognitive development. Limiting the child's bicycling to a defined area may lead to conflicts between the father and the child. Telling the child about the risks of not wearing a helmet may interfere with the child's willingness to ride.

The laboratory calls to report that a hospitalized client's lithium level is 1.9 mEq/L (1.9 mmol/L) after 10 days of lithium therapy. How will the nurse respond to this information? 1. by notifying the PHP of the findings, because the level is dangerously high 2. by monitoring the client closely, because the level of lithium in the blood is slightly high 3. by continuing the administration of the medication as prescribed, because the level is within the therapeutic range 4. by reporting the finding to the PHP so the dosage can be increased, because the level is below the therapeutic range

1 rationale: Any result above 1.5 mEq/L (1.5 mmol/L) is approaching or in the toxic range. The therapeutic range for lithium is 0.6 to 1.2 mEq/L (0.6 to 1.2 mmol/L). Immediate action must be taken. The level is dangerously high, and continued administration of the drug and simple monitoring are unsafe.

A client with multiple injuries from a motor vehicle accident now is permitted out of bed to a chair but is not permitted to bear weight on the lower extremities. When using a mechanical lift to transfer the client, it is essential that the nurse do what? 1. fold the client's arms across the chest 2. place the sling so that the top is below the client's scapulae 3. call the PHP to secure a prescription to use a mechanical lift 4. raise the lift so that the sling is at least 12 inches above the mattress

1 rationale: Folding the arms across the chest maintains both arms in a safe position during the transfer. During a safe transfer, the sling should extend from above the scapulae to the knees to provide appropriate support. The use of a mechanical lift is an independent function of the nurse. Raising the lift so that the sling is at least 12 inches (30.5 cm) above the mattress height is unsafe; during the transfer, the sling should be raised just high enough (3 to 4 inches [7.6 to 10.2 cm]) to clear the mattress.

A client who sustained trauma to the chest as a result of an injury has chest tubes inserted and is attached to a closed chest drainage system. When caring for this client, what should the nurse do? 1. palpate the area around the tubes for crepitus 2. clamp the chest tubes when suctioning the client 3. empty the drainage chamber at the end of the shift 4. change the client's dressing daily using aseptic technique

1 rationale: Leakage of air into the subcutaneous tissue is evidenced by a crackling sound when the area is palpated gently; this is referred to as crepitus. Hemostats should be readily available for any client with chest tubes in the event of a break in the drainage system; otherwise, clamping the tube is not necessary. The system is kept closed to prevent the pressure of the atmosphere from causing a pneumothorax; drainage levels are marked on the drainage chamber to measure output. To minimize the risk of a pneumothorax, the dressing is not changed routinely.

The medical history of a client with osteoporosis indicates renal calculi. Which medication would be contraindicated? 1. os-cal 2. raloxifene 3. ibandronate 4. zoledronic acid

1 rationale: Os-cal (a calcium supplement) should not be prescribed to a client with osteoporosis with a history of urinary stones. Raloxifene may increase liver function test values and worsen hepatic disease. Ibandronate should not be prescribed to clients with gastric problems because of the risks of esophagitis and gastric ulcers. Zoledronic acid should not be prescribed to clients with poor oral hygiene because the medication may cause maxillary osteonecrosis.

A client is hospitalized with an overdose of benzodiazepines and presents with a respiratory rate less than 10 breaths per minute. Which nursing intervention should be provided as the first priority? 1. give oxygen 2. secure airway 3. administer flumazenil 4. assess the intravenous site

1 rationale: Oxygen should be given as the first priority intervention for clients with a respiratory rate below 10 breaths per minute due to an overdose of benzodiazepines. Securing the airway is done before starting benzodiazepine antagonist therapy. Drugs such as flumazenil should be administered after providing the client with a sufficient oxygen supply. An intravenous site should be assessed because flumazenil can cause thrombophlebitis at the injection site.

Hospital administrators for a new facility are formulating a fire evacuation plan as part of the organizational disaster plan. Which is the best resource for the administrators to use during this process? 1. the life safety code 2. the joint commission 3. the centers for medicare and medicaid services 4. the occupational safety and health administration

1 rationale: The Life Safety Code® is a resource published by the National Fire Protection Association that provides guidelines for building construction, design, maintenance, and evacuation. The hospital administrators will use this as a resource during the formulation of the fire evacuation plan. The Joint Commission is an accrediting body that requires 2 disaster safety drills per year; however, this is not the best resource to formulate a fire evacuation plan. The Centers for Medicare and Medicaid Services (CMS) requires every health care facility to practice at least one fire drill or actual fire response once a year. However, CMS is not a resource for formulating a fire evacuation plan. The Occupational Safety and Health Administration can be used as a resource; however, this is not the best resource for a fire evacuation plan.

The nurse is caring for a client with black widow spider bite. Which nursing intervention is most important for the nurse to perform immediately based on priority? 1. apply ice pack 2. massage the bite area 3. monitor blood pressure 4. administer intravenous opiates

1 rationale: The priority intervention for a black widow spider bite in the prehospital setting is to apply an ice pack because cold application decreases the action of neurotoxin. The bite area should not be massaged because it may lead to spreading of the neurotoxin. The client's blood pressure should be monitored while performing ongoing assessments. Intravenous opiates should be administered in a client with frostbite.

The healthcare team is caring for clients in a mass casualty event. Which clients should be given the least priority of care? 1. client reporting leg sprain 2. client reporting hip fracture 3. client reporting renal colic pain 4. client reporting substernal chest pain

1 rationale: The three-tiered triage system in the emergency department includes emergent, urgent, and nonurgent levels in which the clients should be cared for accordingly. A client reporting a leg sprain indicates a nonurgent situation in which care for the client can be delayed. A hip fracture with renal colic pain may not be a life-threatening situation and care for the client can be delayed for a few minutes. A client reporting substernal chest pain is a life-threatening complication and, therefore, the client should be provided with immediate care.

What is the priority of care to promote client safety directly after esophagogastroduodenoscopy? Select all that apply. 1. preventing aspiration 2. reminding the client not to drive 3. monitoring for signs of perforation 4. advising the client to use throat lozenges 5. teaching the client about hoarseness of voice

1, 3 rationale: The priority for care to promote client safety after esophagogastroduodenoscopy (EGD) is to prevent aspiration. Signs of perforation such as bleeding, pain, and fever are also monitored as priority care. Reminding the client not to drive is low priority. The client is advised to use throat lozenges to relieve throat discomfort, which is a low priority care. Hoarseness of voice persists for several days after EGD. Therefore the client is taught about hoarseness of voice, which is considered low priority.

Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do? 1. have the prescription renewed every 48 hours 2. assess the client's condition every hour 3. provide range of motion to the client's elbows every shift 4. document output from the tube and catheter every 2 hours

2 rationale: A restraint impedes the movement of a client; therefore a client's condition needs to be assessed every hour. All restraints are required to be represcribed every 24 hours. Restraints should be removed and activity and skin care provided at least every 2 hours to prevent contractures and skin breakdown. Output from tubes may be monitored hourly, but generally does not need to be documented as frequently as every 2 hours. Generally output from tubes is emptied, measured, and documented at the end of each shift. A client who is in critical condition or in the immediate postoperative period may have urinary output measured hourly because this reflects cardiovascular status.

Which intervention will the nurse implement when assisting a child with a history of aggressive behavior to regain control in the triggering phase of an assault cycle? 1. discuss alternative behaviors to substitute for aggression 2. provide the child with a quiet, low-stimulus environment 3. speak to the child in a calm but firm manner 4. administer medication as needed (PRN) to facilitate de-escalation

2 rationale: In the triggering phase, the client's behavior is nonthreatening and poses no danger to others. Minimizing environmental stimuli and providing a calm, nonthreatening environment likely will serve to help the client de-escalate and regain control. Discussion of substitute behaviors is effective only once the crisis is over (postcrisis phase). As the client escalates, the nurse needs to begin to assume control by presenting a calm but firm tone of voice and demeanor. It is at this time that appropriate oral PRN medications may be helpful.

The nurse finds the respiratory rate is 8 breaths per minute in a client who is on intravenous morphine sulfate. What should the nurse do immediately in this situation? 1. measure other vital signs 2. stop administering the medication 3. elevate the head of the client's bed 4. report to the PHP

2 rationale: Morphine sulfate is an opioid analgesic and can depress the central nervous system, which results in respiratory depression. A respiratory rate of 8 breaths per minute indicates respiratory depression, and the nurse should stop the medication immediately. The nurse can measure the other vital signs after discontinuing the medication administration. Elevating the head of the client's bed ensures proper breathing. Therefore the nurse should elevate the client's bed after discontinuing the medication. The nurse should report to the primary healthcare provider for an appropriate antidote after stopping the medication administration.

The nurse is caring for a client with Parkinson disease. Which is a priority nursing concern? 1. decreased physical mobility related to stooped posture 2. risk for injury related to gait disturbances 3. impaired skin related to drooling 4. pain related to headache

2 rationale: The client with Parkinson disease may fall because of gait disturbances. Decreased mobility and impaired skin are problems but not the priority. Pain is usually not a manifestation of Parkinson disease.

A client is started on a continuous infusion of heparin. Which finding does the nurse use to conclude that the intervention is therapeutic? 1. international normalized ratio (INR) is between 2 and 3 2. prothrombin time (PT) is 2.5 times the control value 3. activated partial thromboplastin time (APTT) is double the control value 4. activated clotting time (ACT) is in the range of 70 to 120

3 rationale: Activated partial thromboplastin time should be 1.5 to 2.5 for the control of heparin therapy. INR and PT are used to evaluate therapeutic levels of warfarin. The ACT increases to a range of 150 to 200 when heparin reaches therapeutic levels.

After a fire in the hospital, a client is found to have dyspnea and gasping breathing. The client also has neck trauma and is unable to speak. Which nursing interventions are most appropriate? Select all that apply. 1. placing a nasogastric tube 2. performing jaw-thrust maneuver 3. performing endotracheal intubation 4. monitoring respiratory rate and oxygen saturation 5. monitoring the heart rate and rhythm continuously

2, 3 rationale: The jaw-thrust maneuver may help in opening a client's airway. Endotracheal intubation may assist the client in obtaining proper breathing. A nasogastric tube should not be placed in the client with neck trauma because it could enter the brain. Monitoring the respiratory rate and oxygen saturation is required after performing the jaw-thrust maneuver and endotracheal intubation may be required in this situation. Heart rate and rhythm should be monitored continuously in an emergency condition to assess the condition after the client has stabilized breathing.

What are the priority nursing interventions for a grieving client? Select all that apply. 1. recording client details 2. allowing the client to express feelings 3. monitoring the psychologic behavior of the client 4. counseling the family members about diet modifications 5. respecting the feelings of the client and creating a comfortable environment

2, 5 rationale: The priority nursing interventions for a client in grief includes providing an environment that allows the client to express his or her feelings, such as anger, fear, and guilt. Respecting the client's privacy and need or desire to talk (or not) is important and helps create a comfortable environment. Recording client details is possible only when the client is stabilized. Monitoring the psychologic behavior of the client is a moderate priority. Counseling the client's family members about lifestyle modifications is the last priority because this is of low importance.

The primary healthcare provider prescribes 80 mg of furosemide by mouth daily. Before administering the furosemide, which action is the priority? 1. weigh the client 2. assess skin turgor 3. check the potassium lab results 4. check the total intake and output for the last 24 hours

3 rationale: Although assessing skin turgor, weighing the client, and checking the intake and output are all a part of assessing for hydration, the potassium level should always be checked before administering furosemide. Administering furosemide in the presence of hypokalemia could cause cardiac arrhythmias.

The mother of a 2-year-old child calls her neighbor, who is a nurse, exclaiming that her child just ate some automatic dishwasher powder. What should the nurse tell the mother to do first? 1. give syrup of ipecac 2. wash the child's lips 3. call the poison control center 4. offer burnt toast with some milk

3 rationale: Dishwashing powder is a caustic chemical that requires a specific antidote, and the personnel at the Poison Control Center are best qualified to advise the mother. Syrup of ipecac, which induces vomiting, is contraindicated in children. Washing the child's lips may provide comfort, but it will not prevent injury. Neither burnt toast nor milk is recommended as an antidote for poisoning caused by dishwasher powder.

A client is receiving an antipsychotic medication. When assessing the client for signs and symptoms of pseudoparkinsonism, the nurse will be alert for which complication? 1. drooling 2. blurred vision 3. muscle tremors 4. photosensitivity

3 rationale: Drug-induced parkinsonism presents with the classic triad of adaptations associated with Parkinson disease: rigidity, slowed movement (bradykinesia), and tremors. The anticholinergic effects of antipsychotic medication cause dry mouth, not drooling. Neither dry mouth nor drooling is related to pseudoparkinsonism. Blurred vision and photosensitivity are side effects of anticholinergic, not antipsychotic, medications.

A pregnant woman in her second trimester arrives at the local health department, requesting a flu shot. The client states that she gets the flu vaccine every year and has never had an adverse reaction. What action should the nurse perform? 1. do not administer the vaccine until checking with the healthcare provider 2. do not administer the vaccine due to pregnancy contraindication 3. administer the usual dose of the vaccine 4. administer half the usual dose of the vaccine

3 rationale: Influenza is more likely to cause severe illness in pregnant women than in women who are not pregnant. Changes in the immune system, heart, and lungs during pregnancy make pregnant women more prone to severe illness from influenza as well as hospitalizations and even death. There is no need to check with the healthcare provider before administration. The seasonal flu shot has been given safely to millions of pregnant women over many years. Flu shots have not been shown to cause harm to pregnant women or their babies. Flu shots are not contraindicated; however, the nasal vaccine is. There is no indication that dosages should be altered. also - i've read that LIVE vaccines are a no go for pregnant women. the flu shot isn't a live vaccine

During a routine clinic visit of a client who has myasthenia gravis, the nurse reinforces previous teaching about the disease and self-care. The nurse evaluates that the teaching is effective when the client states which information? 1. plan activities for later in the day 2. eat meals in a semirecumbent position 3. avoid people with respiratory infections 4. take muscle relaxants when under stress

3 rationale: Respiratory infections place people with myasthenia gravis at high risk because they do not cough effectively and may develop pneumonia or airway obstruction. Activity should be conducted earlier in the day before the energy reserve is depleted; periods of activity should be alternated with periods of rest. The client should eat sitting in a chair to prevent aspiration. Taking muscle relaxants when under stress is contraindicated; these potentiate weakness because of their effect on the myoneural junction.

Which should the nurse include in the plan of care to decrease the risk for drown injury for a school-age client? 1. securing seatbelts properly 2. using a low heat setting when cooking 3. recommending enrollment in swimming lessons 4. making sure smoke detectors are installed in the home

3 rationale: The nurse should include a recommendation to enroll the client in swimming lessons in the plan of care for a school-age client to decrease the risk for drown injury. The nurse would include seatbelt education in the plan of care for the school-age client to decrease the risk of injury while riding in a motor vehicle. The nurse would include using a low heat setting when cooking and making sure smoke detectors are functional in the home in the plan of care to decrease the risk for burn injury.

Which drug does the nurse recognize as an effective mood-stabilizing drug used in clients with bipolar disorder and in the acute treatment of mania and prevention of recurrent mania and depressive episodes? 1. doxepin 2. clozapine 3. amitriptyline 4. lithium carbonate

4 rationale: Lithium carbonate is often the first choice of treatment, once primary acute mania has been diagnosed, to calm acute manic symptoms and relieve recurrent mania. Doxepin and amitriptyline are antidepressants used to treat depression but not mania. Clozapine is an antipsychotic medication used to control hallucinations and delusions in patients with psychosis but is not a first-line drug because of its side effects, which include seizures and significant weight gain.

The nursing student is learning about common chemical agents of terrorism. The nursing instructor presents a situation where the victims have burned or blistered skin and describes the agent as a brown gas that has a garlic-like odor. What statement made by the nursing student indicates effective learning? 1. the clients were exposed to sarin 2. the clients were exposed to tularemia 3. the clients were exposed to phosgene 4. the clients were exposed to mustard gas

4 rationale: Mustard gas is yellow to brown and has a garlic-like odor. The gas irritates the eyes and causes skin burns and blisters. So, the nurse would conclude that the clients were exposed to mustard gas. Sarin is a nerve gas that causes death by paralyzing the respiratory muscles. Tularemia is a biologic agent of warfare. It is not a gas and does not cause burned or blistered skin. Phosgene is a colorless gas that causes severe respiratory distress, pulmonary edema, and death.

After taking a typical antipsychotic medication for 1 month, a client reports, "I feel stiff, my hands shake, and I started drooling." The picture illustrates the client's physical status observed by the nurse in the clinic. What extrapyramidal side effect does the nurse conclude that the client has developed? 1. dystonia 2. akathisia 3. tardive dyskinesia 4. pseudoparkinsonism

4 rationale: Pseudoparkinsonism has adaptations similar to those of Parkinson disease (e.g., shuffling gait, tremors, rigidity, bradykinesia). Pseudoparkinsonism, an extrapyramidal side effect of typical antipsychotics, can occur any time after initiation of therapy. Dystonia is muscle spasms of the face, tongue, head, neck, jaw, and back, usually causing exaggerated posturing of the head. Akathisia is exhibited by motor restlessness. Tardive dyskinesia is exhibited by facial, ocular, oral/buccal, lingual/masticatory, and systemic movements.

A nurse explains to the parents of a toddler why 2-year-old children are at risk for lead poisoning. What major risk factor does the nurse include in the discussion? 1. lead is readily available to them 2. their vascular systems are underdeveloped 3. motor vehicle use and pollution have increased 4. they explore the environment by touching and tasting

4 rationale: Young children have a propensity for putting things in their mouths; children in this age group use this method to explore the environment. Although lead is likely to be present in older homes and apartments, it is the activity of putting things in the mouth that is the primary cause of lead poisoning. A toddler has a well-developed vascular system. Although gas fumes in areas of heavy traffic have increased pollution, the gasoline used today does not contain lead.

Which nursing interventions are beneficial in the event of fire in the hospital? Select all that apply. 1. opening the doors and windows 2. moving ambulatory clients in wheelchairs to a safe location 3. putting out the fire first and then removing the clients from fire area 4. asking ambulatory clients to help push wheelchair clients out of danger 5. maintaining injured clients' respiratory status manually until removed from the fire area

4, 5 rationale: The nurse should ask ambulatory clients to help push wheelchair clients out of danger. The nurse should maintain the respiratory status of injured clients manually until they can be removed from the fire area. The nurse should close the doors and windows to try to contain the fire. The nurse should move the bedridden clients from the fire area in a wheelchair or by stretcher. The nurse should first remove the clients from the fire area and let professional responders put out the fire.