HESI - Infection control

Herpes zoster

- Reactivated version of chicken pox - Shingles - Nerve pain - Itchy lesions

Which suicide method would indicate a low threat of lethality? A.) Hanging B.) Ingesting pills C.) Jumping from a tall bridge D.) Poisoning with carbon monoxide

B.) Ingesting pills Ingesting pills is considered the least lethal of these suicide methods, because it is considered slower. Hanging, jumping, and carbon monoxide poisoning are all quicker and therefore more lethal methods.

Mafenide acetate (Sulfamylon) for burn patient consideration

- Premedicate patient with analgesics - This medication causes severe burning pain for up to 20 minutes after the application.

Chicken pox contagion

- Droplet - Infectious 1 to 2 days before lesions appear and UNTILL the lesions have crusted

Botulism manifestations

- Dysphasia - Dry mouth - Drooping eyelids - Blurred vision - Vomiting - Diarrhea.

Dietary need for wound healing

- High protein - High calorie - Penut butter

Partial thickness or second degree burns

- The epidermis and the underlying dermis are both injured and destroyed - Painful, red, and moist and are known for their blistering appearance.

HIPPA police department policy

Police officers have permission to access medical records concerning accidents.

Transsphenoidal hypophysectomy

Procedure to remove an adenoma or tumor from the pituitary gland. - AVOID COUGHING IN POST-OP

HIV precautions

Standard precautions.

Liquid nystatin teaching:

Swish for 2 min then swallow, no food or drink for awhile.

TB drugs

RIPE - Rifampin - Isoniazid - Pyrazinamide - Ethambutol

Escharotomy

A surgical incision into the eschar to relieve the constricting effect of the burned tissue.

Ethambutol effects

Optic neuropathy.

At which height is it no longer safe for a toddler to sleep in a crib?

- A toddler who has reached the height of 35 inches should be transitioned from a crib to a bed. At that height, children likely can pull themselves up and over the crib rail, putting them at risk for injury. - Toddlers 26, 28, and 33 inches in height can remain in a crib because falling is not a concern.

Dumping syndrome

- A group of symptoms that are caused by rapid gastric emptying - Rapid gastric emptying is a condition in which food moves too quickly from your stomach to your duodenum - Common in a Whipple procedure

Why is an infection caused by Neisseria gonorrhoeaeparticularly troublesome for a female client?

- 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.

How long would the nurse maintain isolation of a child with bacterial meningitis? A.) For 12 hours after admission B.) Until the cultures are negative C.) Until antibiotic therapy is completed D.) For 48 hours after antibiotic therapy begins

D.) For 48 hours after antibiotic therapy begins Most children 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 birth factors place the neonate at risk for sudden infant death syndrome (SIDS)?

- Birth order - Multiple births - Low Apgar score

Which nursing intervention would be implemented routinely in the immediate recovery period after a client has a vacuum aspiration abortion? A.) Giving the client the prescribed oxytocic medication B.) Preparing the client for discharge within 30 minutes C.) Teaching the client about the various methods of birth control D.) Encouraging the client to take the prescribed antibiotic medication

D.) Encouraging the client to take the prescribed antibiotic medication Prophylactic antibiotics after a vacuum extraction abortion decrease the incidence of infection. Oxytocics are not used routinely after an abortion unless there is excessive vaginal bleeding. The client is usually observed for 1 to 3 hours before being discharged. Birth control instructions should be given before the abortion; a client is not receptive to teaching immediately after the procedure.

Interview for abused patients

1-on-1 in a private room.

Which findings noted during assessment would lead the nurse to determine that a client is at an increased risk for infection? Select all that apply. One, some, or all responses may be correct. A.) Surgical incision B.) Urinary catheter C.) Antibiotic therapy D.) Intravenous access E.) Diminished appetite

A.) Surgical incision B.) Urinary catheter C.) Antibiotic therapy D.) Intravenous access Findings that increase the risk of infection in a client would be the presence of a surgical incision, a urinary catheter, and an intravenous access. These are all portals of entry for microorganisms. Antibiotic therapy can lead to a suprainfection that eliminates the normal flora.

A client reports being physically abused by his or her partner. Which interventions would the nurse include in the plan of care? Select all that apply. One, some, or all responses may be correct. A.) Press for information. B.) Assess level of danger. C.) Use medical terminology. D.) Have others in the interview. E.) Notify adult protective services.

B.) Assess level of danger. E.) Notify adult protective services. Guidelines for interviewing a victim of domestic violence include assessing the current level of danger and notifying adult protective services. The nurse would explain to the client the required process for notifying the agency of the abuse. The nurse would not press for information the client is not comfortable providing. The nurse would use language the client understands and avoid medical terminology. The nurse would also interview the client in a private area without others around.

Autograft transplant

From one body site to another in the same person.

Parkland formula

- 4mg/ kg of body weight - First half within the first 8 hours - Rest over 16 hours

For which conditions is obesity a known risk factor? Select all that apply. One, some, or all responses may be correct. A.) Gout B.) Atrial fibrillation C.) Multiple myeloma D.) Gallbladder disease E.) Diverticular disease F.) Inflammatory bowel disease

A.) Gout D.) Gallbladder disease E.) Diverticular disease Gout, gallbladder disease, and diverticular disease are affirmatively linked with obesity. Obesity is not a known risk factor for atrial fibrillation, multiple myeloma, or inflammatory bowel disease.

Teaching for TB drugs

AVOID ALCOHOL!!!

Which parent teaching would the nurse provide for an infant who has eczema? A.) Ensuring physical growth B.) Identifying causative factors C.) Providing adequate hydration D.) Applying daily topical corticosteroids

C.) Providing adequate hydration - Adequate skin hydration is key to maintaining skin integrity and preventing eczema flares that may lead to infections. - Although ensuring growth is important for any infant, skin hydration is a priority for infants with eczema. - An exact cause of eczema may never be identified. - Topical corticosteroids are often used for eczema flares, but are not indicated daily.

Iatrogenic

Caused by treatment or procedure.

Rifampin side effects

- Red-orange tears and urine, stool, and sweat - Contraceptives don't wor

Which information about infection prevention would the nurse include when planning discharge teaching for a client being treated with chemotherapy for leukemia? A.) "Wash hands before eating and after using the toilet." B.) "Take your temperature daily and report elevations of 1 °F (0.5 °C)." C.) "Avoid use of antimicrobial soaps when showering or bathing." D.) "Clean your toothbrush daily by running it through the dishwasher." E.) "Increase your daily intake of fresh fruits and vegetables."

A.) "Wash hands before eating and after using the toilet." Hand washing is essential to infection prevention and will be performed by the client and all caregivers and visitors. Even mild temperature elevation may indicate severe infection in the immunocompromised client and should be reported by the client to the health care provider. Toothbrushes should be cleaned daily in the dishwasher or with a bleach solution to reduce risk for infection. Antimicrobial soaps are recommended for immunocompromised clients, especially when cleaning the axillary and genital areas. Fresh fruits and vegetables carry bacteria; cooked fruits and vegetables generally are recommended for immunocompromised individuals.

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

D.) Disaster Mortuary Operational Response Teams (DMORTs) DMORTs are a 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.

Curling's ulcer

- An acute duodenal ulcer that develops in clients who have severe body surface burns - Coffee ground vomitus, or aspirate, is a term to describe hemoglobin that is darker because it has been denatured by acid in the stomach.

Whipple procedure

- Pancreaticoduodenectomy - An operation to remove the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder and the bile duct. - The remaining organs are reattached to allow you to digest food normally after surgery.

Abduction pillow

A hip abduction pillow is a soft but firm foam pillow that is placed between the thighs and strapped onto the patient's legs while they are in a resting position. This aids in keeping the body stable and prevents an abducting motion that could cause pain or further injury post-surgery.

Which substance can cause life-threatening dysrhythmias when inhaled? Select all that apply. One, some, or all responses may be correct. A.) Glue B.) Gasoline C.) Nicotine D.) Cannabis E.) Paint thinner

A.) Glue B.) Gasoline E.) Paint thinner Inhaled substances that can lead to life-threatening dysrhythmias include glues, gasoline, and paint thinner. Nicotine and cannabis can cause lung cancer but do not cause dysrhythmias.

Labs to monitor for all TB drugs

Liver functions test.

Wilms tumor

Malignant tumor of kidneys.

What clinical condition is associated with lead poisoning?

Anemia.

Which instructions would the nurse teach a client about preventive measures for Lyme disease? A.) "Wear dark-colored dresses." B.) "Tuck your shirt into your pants." C.) "Obtain a Lyme disease vaccination annually."

B.) "Tuck your shirt into your pants." Lyme disease is a vector-borne disease caused by the spirochete Borrelia burgdorferi and results from the bite of an infected deer tick, also known as the blacklegged tick. Light-colored, rather than dark-colored clothing is preferred to spot the ticks easily, thereby preventing an insect bite and infection. Wearing closed shoes and boots and tucking the shirt in the pants prevent the entry and the bite of the blacklegged tick. Bathing should be done immediately after being in an infested area to prevent any possible infection. Currently, there is not a vaccination available for the prevention of Lyme disease.

The nurse recognizes that premature infants are at risk for increased sensitivity to medications due to which factors? Select all that apply. One, some, or all responses may be correct. A.) Body size B.) Blood-brain barrier C.) Renal drug excretion D.) Hepatic drug metabolism E.) Protein binding of the drugs

B.) Blood-brain barrier C.) Renal drug excretion D.) Hepatic drug metabolism E.) Protein binding of the drugs In infants, immaturity of the pharmacokinetic processes, including the blood-brain barrier, renal drug excretion, hepatic drug metabolism, and protein binding of the drugs, as well as drug absorption, all contribute to increased sensitivity to drugs. Body size does not contribute to the infant's increased sensitivity to pharmacological agents.

After the nurse educator finishes teaching a group of new staff nurses about postoperative care of the vascular bypass client, which statement by the new nurse indicates that more education is needed? A.) "A cool, pale extremity can indicate vascular reocclusion." B.) "Hourly assessment of the extremity is needed for the first 24 hours." C.) "A client report of throbbing pain typically indicates vascular reocclusion." D.) "Ongoing pain even after use of the patient-controlled analgesia (PCA) pump indicates possible occlusion."

C.) "A client report of throbbing pain typically indicates vascular reocclusion." Throbbing pain occurs with the pulsations of arterial blood flow and is common after arterial bypass as blood flow is restored to the extremity. Occlusive pain is often severe, continuous, and aching or burning. A cool, pale extremity without a pulse indicates occlusion. Perfusion of the affected extremity is monitored in the first 24 hours after surgery. The PCA pump may not be effective against occlusive pain, which is caused by ischemia of tissues.

A client exhibits dysphasia, dry mouth, drooping eyelids, blurred vision, vomiting, and diarrhea. Within 24 hours, the client develops bilateral cranial nerve impairment and descending weakness. Which bioterrorism agent presents with these clinical manifestations? A.) Plague B.) Anthrax C.) Botulism D.) Smallpox

C.) Botulism These symptoms are found with botulism. With anthrax and smallpox, a rash will be noted. Symptoms of lymphatic plague include fever and chills, painful lymphadenopathy, gastrointestinal symptoms, and progressive weakness.

A hospitalized client develops an infection at a catheter insertion site. The nurse uses the term iatrogenic when describing this infection. Which rationale explains the nurse's comment? A.) Poor personal hygiene is the cause. B.) Inadequate dietary intake is the cause. C.) The client's developmental level is the cause. D.) A procedure performed at the hospital is the cause.

D.) A procedure performed at the hospital is the cause An iatrogenic infection is one caused by health care providers or therapy. Poor personal hygiene, inadequate dietary intake, and the client's developmental level are not the causes of an iatrogenic infection.

Which nursing intervention is the priority for a client on intravenous medication who is experiencing an anaphylactic reaction? A.) Elevate the lower extremities of the client. B.) Start a normal saline infusion immediately. C.) Report to the primary health care provider immediately. D.) Stop intravenous medication and administer epinephrine

D.) Stop intravenous medication and administer epinephrine Intravenous medications can cause an anaphylactic reaction. During anaphylactic reactions, the nurse would immediately stop the intravenous medication and administer epinephrine (adrenaline). The nurse can elevate the client's lower extremities, but only after administering epinephrine (adrenaline). The nurse can start a normal saline infusion and report to the primary health care provider, but only after stopping the intravenous medication and administering epinephrine (adrenaline).

Which is an example of a sentinel event? A.) A splenectomy is done on the wrong client. B.) Vital signs are taken every 2 hours instead of every 4 hours per hospital policy. C.) The confused client falls out of bed because the nurse forgot to put up the siderails as ordered. D.) The client receives the incorrect antibiotic in the holding area before a surgical procedure.

A.) A splenectomy is done on the wrong client. A sentinel event is an unexpected occurrence involving death, serious physical injury, or psychological injury. An example of a sentinel event is a splenectomy performed on the wrong client. This could result in long-term effects in the client who did not require a splenectomy, as well as the client who needed the procedure but did not receive it as planned. The nurse has the authority to take vital signs more frequently if deemed necessary, as long as it is not more frequent than hospital policy. The confused client who falls out of bed because the nurse did not put up the ordered siderails is an example of negligence. The client receiving the wrong antibiotic is an example of a medication error.

Which information about decreasing the risk for complications would the nurse provide to a pregnant adolescent who remains sexually active with other partners? Select all that apply. One, some, or all responses may be correct. A.) Calcium consumption B.) Exercise C.) Folic acid D.) Condom use E.) Prenatal care

A.) Calcium consumption B.) Exercise C.) Folic acid D.) Condom use E.) Prenatal care The nurse would provide information on nutrition, which would include consuming enough calcium for bone strength. Exercise is important to maintain health, control blood pressure, and prevent too much weight gain. Folic acid supplementation prevents neural tube defects. Condom use is essential because pregnancy does not prevent the client from acquiring sexually transmitted infections. Prenatal care is essential to monitor fetal growth and detect complications early.

A 2-year-old child is admitted with multiple fractures and bruises, and abuse is suspected. Which nursing assessment findings support this suspicion? Select all that apply. One, some, or all responses may be correct. A.) Bedwetting B.) Thumb-sucking C.) Difficulty consoling D.) Underdevelopment for age E.) Demands for physical closeness

C.) Difficulty consoling D.) Underdevelopment for age Abused children may be difficult to console because they have not had positive past interpersonal experiences. Failure to thrive is often seen in abused children. It results from emotional stress as well as from neglect of physical needs. The task of nighttime bladder training may not be completed until 4 or 5 years of age, and sometimes even later. Thumb-sucking is not noteworthy because many children, not just those who are abused, continue to suck their thumbs for several years. Abused children do not seek physical closeness because their needs for comfort have not been met in the past.

When the registered nurse (RN) is working on a client care team, which assignment made by the RN indicates ineffective delegation? A.) The licensed practical nurse (LPN) will pass all oral medications. B.) The RN will complete all client admissions. C.) The unlicensed assistive personnel (UAP) will bathe the critically ill client. B.) The state-tested nursing assistant (STNA) will obtain and record vital signs.

C.) The unlicensed assistive personnel (UAP) will bathe the critically ill client. Delegation requires the RN to know how to delegate work appropriately. The RN must know the level of competency of the delegatee, as well as the responsibility, accountability, and authority. Assigning the UAP the task of bathing a critically ill client is inappropriate because this activity would require assessment skills of the RN. LPNs can pass all oral medications as it is within their scope of practice. The RN would perform all admission assessments. The STNA is trained to obtain and record vital signs.

Silvadene

Used to treat burns and open vesicles. - Prevent sepsis

Which question will the nurse ask to assess a client's potential exposure to inhaled environmental irritants or toxic gases? A.) "Do you garden?" B.) "Are there ashtrays in your home?" C.) "How much water or fluids do you drink daily?" D.) "What type of work have you done in the past?"

D.) "What type of work have you done in the past?" The nurse will ask about a client's occupation to obtain history of exposure to occupational irritants like chemicals, fumes, or fine particles. Asking about hobbies may help in obtaining information about exposure to some irritants, but gardening does not increase risk for inhaled irritants or toxic gases. Asking about ashtrays in the home will help determine if the client is exposed to secondhand smoke but will not address exposure to environmental irritants or toxic gases. Asking about fluid intake may be helpful in developing a plan of care for a client but does not assess for toxic gas exposure or environmental irritants.

Which instruction on infection prevention would the nurse include when providing discharge education to a client who received a cadaveric renal transplant? A.) Avoid eating from buffets. B.) Obtain annual flu vaccinations. C.) Perform regular hand hygiene. D.) Stay away from crowded areas. E.) Report a temperature greater than 100.5°F.

A.) Avoid eating from buffets. B.) Obtain annual flu vaccinations. C.) Perform regular hand hygiene. D.) Stay away from crowded areas. E.) Report a temperature greater than 100.5°F. Clients who receive an organ transplant need to take immunosuppressant medications for the rest of their lives to prevent organ rejection. These medications put the client at increased risk for infection. The nurse would provide infection prevention teaching to the client after renal transplant, which would include instructions to avoid eating from buffets, get an annual flu vaccine, practice regular hand hygiene, and avoid crowded areas. Clients would also be instructed to report a temperature greater than 100.5°F to their health care provider as it could indicate infection or organ rejection and requires treatment.

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

A.) Medical Reserve Corps (MRC) 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 medical 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.

Which would be the priority to maintain the hospital environment when a large number of clients walk into the emergency department (ED) asking to be treated for minor injuries sustained from the detonation of a car bomb? A.) Triage the injuries. B.) Initiate a decontamination process. C.) Document each name and address. D.) Direct to have a seat in the waiting area.

B.) Initiate a decontamination process. Green-tagged clients or the walking wounded who self-transport to a health care facility may unknowingly carry contaminants from a nuclear, biological, or chemical incident into the hospital environment. These issues must be anticipated and appropriate decontamination measures implemented. Triaging the injuries would not be needed because the clients walked into the ED. Documenting each name and address is essential; however, this is not the priority. Directing clients to sit in the waiting area encourages potential contamination of the hospital environment.

Which action by a client with peripheral arterial disease indicates that more teaching about how to manage the disease is needed? A.) Applying a hot water bottle to the abdomen B.) Using a heating pad to warm the extremities C.) Drinking a warm cup of tea when feeling chilly D.) Turning the room thermostat above 72°F (23.3°C)

B.) Using a heating pad to warm the extremities The client's extremities are less able to respond to thermal stress because of peripheral vascular problems, and burns may occur with the application of a heating pad to the extremities. Applying heat to the abdomen causes reflex dilation of the arteries in the extremities and increases blood flow without untoward effects. Raising the internal temperature by drinking warm fluid prevents vascular constriction and warms the extremities. Increasing heat of the external environment will safely help prevent arterial constriction and improve client's peripheral circulation.

Which recommendation would the nurse give to the parent of a preschool-age client who calls the pediatric clinic after dropping a mercury thermometer at home? A.) "Hang up and call 9-1-1 for further treatment." B.) "Contact the poison control center immediately." C.) "Clean up the spill using paper towels and disposable gloves." D.) "Bring your child to the clinic immediately for further assessment."

C.) "Clean up the spill using paper towels and disposable gloves." After dropping a mercury thermometer at home, the parent should clean up the spill using paper towels and disposable gloves to avoid the risk of inhalation injury for the preschool-age client. There is no reason to activate emergency medical services, contact the poison control center, or bring the child to the clinic for further assessment after dropping a mercury thermometer at home.

The nurse is educating a client on postoperative care after a transsphenoidal hypophysectomy. Which action made by the client is incorrect? A.) Performing deep-breathing exercises B.) Bending at the knees to pick up objects C.) Coughing to clear pulmonary secretions D.) Taking stool softeners to prevent straining

C.) Coughing to clear pulmonary secretions A client who underwent a transsphenoidal hypophysectomy should avoid coughing after surgery as it increases incisional pressure and can, in turn, cause a cerebrospinal fluid leak. Therefore this action indicates a need for further teaching. The client should perform deep-breathing exercises, bend at the knees to pick up objects, and take stool softeners to prevent straining with bowel movements.

Which education would the nurse provide the parents of preschool-aged children regarding injury prevention? A. "Preschool-aged children are more prone to falls than are toddlers." B. "Preschool-aged children are at risk for injury because of their poor gross motor skills." C. "Preschool-aged children are less likely to follow rules, which increases the risk for injury." D. "Preschool-aged children are at risk for head injuries from riding a tricycle or balance bike."

D. "Preschool-aged children are at risk for head injuries from riding a tricycle or balance bike." Preschool-aged children are at risk for head injuries from falls while riding a tricycle or balance bike; helmets are critical anticipatory guidance. The preschool-aged child is at a decreased risk for falls when compared with the toddler. Preschool-aged children have better gross motor skills; therefore this decreases their risk of injury. The preschool-aged child is more, not less, likely to follow the rules, which also decreases the risk of injury.

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 A.) Acyclovir B.) Silvadene C.) Gabapentin D.) Wet compresses E.) Contact isolation

A.) Acyclovir B.) Silvadene C.) Gabapentin D.) Wet compresses E.) Contact isolation A client with herpes zoster would receive antiviral medications such as acyclovir. Silvadene can be applied to open vesicles (lesions). 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 action would the nurse take when providing care for a client suspected of having the Ebola virus? A.) Consider cohorting the client. B.) Wear a face mask and gown at all times. C.) Follow standard and droplet precautions. D.) Avoid contact with all body fluids and discharges.

D.) Avoid contact with all body fluids and discharges. Because the Ebola virus is highly contagious and transmitted through all body fluids and discharges, the nurse would avoid coming in contact with any fluids or discharges from the client. The client should be isolated in a private room and not cohorted. Personal protective equipment when caring for a client with the Ebola virus includes gown, gloves, mask, and goggles. Standard, droplet, and airborne precautions would be followed when providing care for this client.

Which occurs immediately after birth that increases the risk for cardiac decompensation in a client with a compromised cardiac system? A.) Increased pressure is placed on the veins. B.) Intra-abdominal pressure is significantly increased. C.) The blood flow to the heart is decreased considerably. D.) Extravascular fluid is remobilized into the vascular compartment.

D.) Extravascular fluid is remobilized into the vascular compartment. During the immediate period after birth the extravascular fluid is remobilized into the vascular compartment, increasing the client's risk for cardiac decompensation. At the moment of birth, the pressure on the veins is removed, the intra-abdominal pressure decreases dramatically, and the blood flow to the heart is significantly increased.

Which provider prescription would the nurse question for a young child with a tentative diagnosis of Wilms tumor? A.) Renal biopsy B.) Abdominal ultrasound C.) Computed tomography scan D.) Magnetic resonance imaging

A.) Renal biopsy - A renal biopsy is an invasive procedure. In the early stages, Wilms tumor is encapsulated. Any disruption of the tumor capsule may precipitate metastasis. - Magnetic resonance imaging, computed tomography, and abdominal ultrasound are all helpful in making the diagnosis.

Which action will the nurse include in the plan of care for victims of a boat accident who sustained submersion injuries? Select all that apply. One, some, or all responses may be correct. A.) Administer oxygen. B.) Obtain 12-lead electrocardiogram (ECG). C.) Assess for gag reflex. D.) Immobilize lumbar spine. E.) Insert long-term intravenous (IV) access.

A.) Administer oxygen. B.) Obtain 12-lead electrocardiogram (ECG). C.) Assess for gag reflex. Interventions to include in the plan of care for victims of a submersion accident include oxygen administration, obtaining a 12-lead ECG, and assessing for gag reflex. If the nurse notices gag reflex is absent, the client may need to be intubated. The nurse will immobilize the cervical spine, not lumbar spine. The nurse will insert two peripheral large-bore IV catheters, not long-term IV access.

Which intervention will the nurse include in a care plan for a client with dementia who wanders? Select all that apply. One, some, or all responses may be correct. A.) Assess and treat pain. B.) Avoid loud music, television, and glaring lights. C.) Have family members monitor client activity when possible. D.) Use chemical or physical restraint at night to keep the client in bed. E.) Place the client at the end of the hall to allow use of the hall for wandering.

A.) Assess and treat pain. B.) Avoid loud music, television, and glaring lights. C.) Have family members monitor client activity when possible. Assessing and treating pain in clients with dementia promotes relaxation and prevents unsafe wandering. Avoiding loud music, television, and glaring lights helps decrease confusion and unsafe sensory overload. When possible, family members or volunteers can be "sitters" for clients by providing safe supervision. Chemical or physical restraint is only used as a last resort; it is generally avoided. Clients with dementia who are prone to wander need to be placed away from stairs and elevators, preferably close to the nurse's station to allow for close monitoring of their activity.

Which substance history of a severe allergic reaction results in avoidance of the cephalosporins such as cefazolin, cefditoren, cefotetan, and ceftriaxone? Select all that apply. One, some, or all responses may be correct. A.) Milk B.) Aspirin C.) Calcium D.) Penicillin E.) Strawberries

A.) Milk B.) Aspirin C.) Calcium D.) Penicillin Use of cephalosporins like cefazolin should be avoided in the client with a history of severe allergic reaction to penicillin because of the potential of cross-sensitivity. The cephalosporin cefditoren should not be administered to the client with a milk allergy because it contains the milk protein caseinate. Bleeding can be magnified with the use of aspirin and the use of the cephalosporins cefotetan or ceftriaxone. The cephalosporin ceftriaxone and calcium should not be administered together because they cause the formation of precipitates.

The nurse is teaching a client who underwent a Whipple procedure regarding the early signs of dumping syndrome. Which information would the nurse include? Select all that apply. One, some, or all responses may be correct. A.) Pallor B.) Sweating C.) Confusion D.) Tachycardia E.) Hypertension

A.) Pallor B.) Sweating D.) Tachycardia Early clinical manifestations of dumping syndrome that the nurse would include are pallor, sweating, tachycardia, palpitations, and vertigo. The client will exhibit confusion between 1.5 to 3 hours after eating. The client would experience hypotension, not hypertension, due to fluid shifts.

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

B.) "Breast-feeding will provide protection against bacteria." 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.

Which types of hepatitis develop into a chronic form of the disease? Select all that apply. One, some, or all responses may be correct. A.) Hepatitis A B.) Hepatitis B C.) Hepatitis C D.) Hepatitis D E.) Hepatitis E

B.) Hepatitis B C.) Hepatitis C D.) Hepatitis D Hepatitis B and C generally develop into chronic hepatitis. Hepatitis D is an incomplete virus that can become chronic and is dependent on the presence of hepatitis B to survive. Hepatitis A and E are acute, self-limiting infections that resolve over time and do not develop into chronic hepatitis.

After teaching the parents of a newborn how to suction using a bulb syringe, which statement made by the parent indicates an understanding of the information? A.) "I will suction the nares first." B.) "I will keep the bulb syringe nearby." C.) "I will depress the bulb before suctioning the mouth or nose." D.) "I will insert the tip of the bulb syringe in the center of the mouth."

C.) "I will depress the bulb before suctioning the mouth or nose." The bulb syringe is depressed before suctioning the mouth or the nose. The mouth should be suctioned first. The bulb should be kept in the crib at all times. When suctioning the mouth, the tip of the bulb should be inserted into one side of the mouth to avoid stimulating the gag reflex.

Fresh fruit and vegetable consideration

Carry bacteria so not for those who are immunocompromised.

The nurse is teaching an adolescent with a sprained ankle how to use one crutch when walking. Which statement indicates that no further teaching is necessary? A.) "I shouldn't use my crutch on stairs." B.) "After a month I can stop using the crutch." C.) "I should place the crutch in front of my bad ankle." D.) "I should use the crutch on the side of my good ankle."

D.) "I should use the crutch on the side of my good ankle." The crutch is positioned on the unaffected side and advanced with the affected leg; the crutch supports the body's weight while the client is walking on the affected leg. The crutch should be used on the stairs to provide a wide base and extra support when the client goes up or down the stairs. A sprained ankle should heal in less than 1 week, after which the crutch should no longer be needed. Positioning the crutch in front of the affected foot will place that foot in a weight-bearing position without support, defeating the purpose of the crutch.

Which would the nurse instruct the unlicensed assistive personnel (UAP) to perform to prevent hip dislocation in a client recovering from a total hip arthroplasty via posterior approach? A.) Raise heels off the bed. B.) Change positions slowly. C.) Use a gait belt during ambulation. D.) Insert abduction pillow between legs.

D.) Insert abduction pillow between legs. The nurse will instruct the UAP to insert an abduction pillow between the legs of a client recovering from total hip arthroplasty via posterior approach to prevent dislocation of the hip. Raising the heels prevents skin breakdown. Changing positions slowly prevents injury from orthostatic hypotension. Using a gait belt during ambulation decreases the risk for falls.

Which areas would the nurse keep in mind when participating in the planning of an organization's emergency preparedness plan?

- Needs for security - Staffing surge situation - Methods of communication - Definition of specific nursing roles Before an event, nurses contribute to the development of emergency response plans to include security needs, staffing for surge situations, methods of communication, and defining specific nursing roles. Activation of telephone trees would occur during an actual disaster.