*HURST REVIEW Qbank/Customize Quiz - Safety and Infection Control

A child who fractured the ulna and radius following a fall is experiencing itching under the cast. What would be an appropriate nursing intervention to help alleviate the itching? 1. Apply a small amount of hydrocortisone cream with a cotton tip applicator. 2. Use a soft, sterile, cotton tip applicator to gently rub area under the cast. 3. Apply warm, dry heat to the outside of the cast with a lightweight heating pad. 4. Circulate air under the cast utilizing a blow dryer on the cool setting.

4. Correct: An acceptable, safe way to try to alleviate itching is to use a blow dryer on the cool setting to circulate air under the cast. This is the only safe option provided. 1. Incorrect: Although you may be thinking that hydrocortisone cream is an antipruritic, keep in mind the safety aspects of cast care. Nothing should ever be placed underneath the cast. Because of the risk of skin breakdown, the parents and child should be cautioned to not attempt to place any medication or object under the cast. 2. Incorrect: Remember safety! Skin breakdown could occur, even when using a "soft" object. Never place anything under the cast to try to reduce itching. 3. Incorrect: Applying heat to the cast would most likely increase the itching and could create moisture under the cast. The use of heat on the cast should be avoided.

The nurse is educating a group of sexually active teenagers about Chlamydia. What should the nurse teach these clients to prevent them from acquiring or transmitting this disease ? Select all that apply 1. Use a latex condom when having sex to protect against Chlamydia. 2. Seek the advice of a primary healthcare provider if there is vaginal discharge or burning on urination. 3. Suggest that the teens be screened for Chlamydia. 4. Reassure the teens that if they have no symptoms, they have no disease. 5. Take prescribed medication if diagnosed with Chlamydia, and repeat screening in three months.

1., 2., 3. & 5. Correct: Consistent use of latex condoms protects against STIs. Although chlamydia may have no symptoms, burning and discharge should be reported for further evaluation. It is recommended that all sexually active young women less than 25 years of age be screened for chlamydia on an annual basis. Medication should be taken as prescribed, and rescreening should occur in 3 months to make sure that there is no more disease present. 4. Incorrect: Chlamydia does not always produce visible symptoms, and, if left untreated, can lead to pelvic inflammatory disease (PID). False security may lead to unsafe sex practices.

A client diagnosed with a brain injury continues to attempt to get out of the bed without assistance. Which nursing interventions would the nurse implement? Select all that apply 1. Ask a familiar person to stay with the client. 2. Apply position change sensor to the bed. 3. Move client closer to the nursing station. 4. Reinstruct the client to not get out of the bed. 5. Provide positive and negative reinforcement.

1.,2. & 3: Correct: Having a person directly monitor the client will decrease the possibility of the client getting out of the bed. In addition, a familiar person in the room can have a calming effect on the client. Bed alerts will notify the healthcare team that the client is moving in the bed. This will result in a quicker response time to evaluate, if the client is trying to get out of bed. The intervention of moving the client closer to the nursing station will increase the observation of the client. This increased visualization can allow the healthcare team to intervene if the client tries to get out of the bed. 4. Incorrect: Due to the brain injury, the client's ability to process information, including instructions is limited. The client may become agitated and exhibit restless behaviors. Reinstructing the client will not be effective if the client is having difficulty processing the initial instructions. 5. Incorrect: Due to the brain injury, cognitive deficits occur resulting in the decreased ability for the client to interpret information. The client will not have the ability to recognize positive reinforcement messages. The client should not be subjected to any negative reinforcement actions.

Which observations should the home health nurse discuss with the parents of a two year old regarding potential safety threats in the home? Select all that apply 1. Security gates at the stairs. 2. Cleaning supplies under sink cabinet. 3. No blinds on windows. 4. Use of space heaters. 5. Water heater temperature 140°F (60°C) 6. Use of tablecloths

2, 4, 5 & 6 Correct: Cleaning supplies should be placed high away from child's reach. Cabinets should have childproof locks. Space heaters need to be checked every year prior to use. Additionally, small children can be burned by space heaters if they get too close. A guard should be applied. Water heaters should be set at no higher than 120°F (48°C). Burns may occur with a 6 second exposure to 140°F water temperature. Children can pull on table cloths and spill hot food or break dishes which could lead to injury. 1. Incorrect: Placing security gates at the stairs will prevent falls. 3. Incorrect: This is not a concern for the child. If there are blinds, the string should be out of the child's reach.

The nurse is caring for a client diagnosed with major depression post electroconvulsive therapy (ECT). What nursing interventions should be included in this immediate post-treatment period? Select all that apply 1. Monitor vital signs every hour for eight hours. 2. Position the client on their side. 3. Stay with the client until fully awake. 4. Provide flexibility in scheduling routine activities. 5. Encourage the client to ambulate in room and hall.

2. & 3. Correct: Positioning on the side will prevent aspiration. Stay with the client until they are fully awake, oriented, and able to perform self-care activities without assistance. Safety is priority. 1. Incorrect: Pulse, respirations, and blood pressure should be monitored every 15 minutes for the first hour. Vital signs every hour are too long immediately post-treatment. 4. Incorrect: The client needs a highly structured schedule of routine activities in order to minimize confusion. Also, immediately post-treatment is too soon to address routine activities. 5. Incorrect: The client should remain in bed during the immediate post-treatment period. The client needs to be fully awake prior to ambulation.

A client is being scheduled for a cat scan (CT) of the abdomen with contrast. When considering client safety, what should be the priority action for the nurse to implement? 1. Verify that informed consent has been provided. 2. Confirm with client the accuracy of allergies listed. 3. Force fluids following procedure. 4. Monitor output following procedure.

2. Correct: When considering client safety, the nurse should confirm allergies with the client. Clients should be asked about allergies to iodine or shellfish. The radiocontrast agents in the dye contain iodine and have resulted in severe reactions and even death in a few cases. If the client is allergic to iodine, the healthcare provider should be notified before the CT is performed. The use of contrast dye for the procedure will typically be omitted to avoid the risk of a severe reaction. 1. Incorrect: It is very important that a client receive information regarding risks and benefits of a procedure before providing consent (informed consent), but assuring that the consent was provided is not the priority for client safety over the risk of a severe reaction to the dye. 3. Incorrect: Again, it is very important to implement increased fluid intake following procedures, such as this CT of the abdomen, to help flush the dye through the kidneys. However, the safety priority remains the potential for a severe reaction that should be avoided by asking about allergies to iodine. 4. Incorrect: Monitoring urine output is an important nursing action following the CT because sometimes dye can lead to kidney problems or can increase problems in clients with existing renal disease. But this is not a priority over assessing for allergies that could lead to severe reactions.

A client admitted to a long-term care facility is legally blind and partially deaf. How would the nurse best provide for the client's safety in the event of an emergency? Select all that apply 1. Have roommate lead client out of the room to safety area. 2. Assign a specific UAP every shift to escort client to safety. 3. Research established protocols utilized by emergency groups. 4. Discuss best communication methods with client and family. 5. Plan for the supervisor to be responsible for evacuating the client.

3 & 4. Correct: When faced with a new or challenging situation involving client safety, the nurse manager should employ the Nursing Process to assess needs and collect contributing data. Asking for input from emergency preparedness groups, such as the Red Cross or FEMA, could provide ideas about assisting individuals with sensory deficits. Secondly, the nurse should discuss the situation with both client and family to determine appropriate methods of communicating with client, particularly in an emergency situation. 1. Incorrect: The responsibility for client safety should never be placed on a roommate or even family members. Staff should be accountable for client safety at all times. 2. Incorrect: Assigning a specific UAP each shift to locate and escort client to a safe area would be confusing. Changing protocols every shift creates a hazardous situation for staff and clients. 5. Incorrect: The facility supervisor is responsible for all aspects of an emergency, including activation of alarms, coordinating evacuation of staff and clients, and initiating facility emergency protocols such as closing fire doors or turning off oxygen valves. It would not be safe for the supervisor to also be responsible for a single individual.

The nursing supervisor is reviewing several instances in which restraints have been used. The nurse is aware the only acceptable use of restraints is what? 1. An elderly male had a chest restraint applied after crawling over bed rails several times. 2. An Alzheimer client's room door is closed to prevent wandering during shift change. 3. A confused client with a closed head injury had hand mitts applied after pulling out IV 4. A dementia client with sundowners is placed in Geri-chair with lap belt at nurse's station.

3. CORRECT: Restraints are considered a last resort when caring for a client, whether soft cloth or chemical restraints. The most acceptable use is to prevent a client from harming self or others. In this instance, a confused client has previously pulled out a prescribed IV. Therefore, the use of hand mitts is the most appropriate, least-restrictive method to prevent the client from further self-harm. 1. INCORRECT: There are several problems here. The client had side rails up, which are considered a form of restraint and in many facilities are no longer permitted. By applying a chest restraint, the client has been restrained twice. Just because a client is elderly does not mean restraints are needed. This restraint is not acceptable. The nurse should provide regular toileting periods and determine why this client is climbing out of bed. 2. INCORRECT: Closing a client into a room is overly restrictive and unsafe. This Alzheimer's client needs to be observed and closing the room door prevents visual access. Additionally, closing the door may violate fire safety codes in certain facilities. At shift change, when staff is occupied with report, special arrangements should be made so that the client can be observed and not restrained. 4. INCORRECT: Depending on the facility, placing a client upright at night, using a Geri-chair and a lap belt is overly restrictive. A client with dementia is challenging, particularly in the presence of sundowner syndrome. However, keeping a client upright all night, belted into a chair for the purpose of observation, is neither safe nor healthy for the client.

The nurse is preparing to educate a client about human papillomavirus (HPV). What information should the nurse include? 1. There is no vaccine to prevent HPV. 2. HPV is the cause of most ovarian cancers. 3. The only way to prevent HPV is refraining from any genital contact with another. 4. HPV is cured by removal of genital warts.

3. Correct: This is a true statement. Latex condoms have been associated with lower risk, however, there is still a risk of coming into contact with the virus even when a condom is used correctly. 1. Incorrect: There is a vaccine against the human papillomavirus. 2. Incorrect: HPV is the cause of most cervical cancers. 4. Incorrect: Even after genital warts are removed, HPV remains, and viral shedding will continue.

A roommate overhears the primary healthcare provider discussing a client's laboratory results, including a positive HIV test. The roommate requests to be moved immediately to another room. In what priority order should the nurse complete these tasks? Encourage the client to verbalize feelings regarding situation. Educate roommate about transmission of HIV and AIDS. Contact social services to address client's future needs. Transfer roommate to another location as soon as available. Notify nurse manager regarding breach in confidentiality. Drag and Drop the items from one box to the other

The first action by the nurse is to address the roommate's concerns and fears about contracting HIV by presenting information regarding disease transmission. Next, since this situation represents a definite breach of confidentiality, it must then be reported to the nurse manager. Third, despite educating the roommate on modes of transmission, the nurse should attempt to honor the request to be moved to another room. Fourth, address the roommate's needs, by encouraging the client to express feelings about the diagnosis and current situation. Additionally, the client will have other needs related to the diagnosis which can best be handled by the social services department.

Which is the correct method for removing personal protective equipment (PPE)? 1. Contaminated gloves should be removed in the client's room. 2. The glove that is removed first should be placed in the wastebasket before the other glove is removed. 3. Remove face shield or goggles first. 4. Shoe covers should be removed last.

1. Correct: Avoid contaminating self, others, or environment when removing equipment. 2. Incorrect: The first glove is held in the still gloved hand and the second glove is slid over the first removed glove. 3. Incorrect: Hand hygiene is performed before removing face shield or goggles. 4. Incorrect: Shoe covers are removed with gloved hands.

Which information should the nurse plan to teach family members of a client diagnosed with hepatitis B? 1. Do not share personal items with the client, such as razors or toothbrushes. 2. Wash dishes separately from the rest of the family's. 3. Wear a surgical mask when in close proximity to the client. 4. Use a separate bathroom from the client.

1. Correct: Hepatitis B is a bloodborne pathogen that can spread via sharing personal items, such as razors or toothbrushes where infected blood can get into a person's cut, mucous membranes, etc. 2. Incorrect: Unlike some forms of hepatitis, Hepatitis B is not spread through sharing eating utensils, contaminated food or water. Hepatitis B is spread by infected blood or body fluids. 3. Incorrect: Hepatitis B is not airborne, therefore, there is no need to wear a mask. 4. Incorrect: Hepatitis B is not spread by sharing a bathroom. It is blood borne, not spread by the fecal route.

What action by the nurse is most helpful when responding to a bomb threat phone call? 1. Ask where and when the bomb is going to explode. 2. Quickly terminate the conversation and call in the bomb threat. 3. Document on the hospital Bomb Threat Checklist. 4. Immediately seek cover and warn others.

1. CORRECT. The nurse should keep the caller on the phone for as long as possible and try to obtain information, while being alert for voice characteristics and background noises. While keeping the caller on the line, the nurse should motion to another employee to call in the bomb threat. 2. INCORRECT. You should keep the caller on the line and signal someone to call in the threat. Keeping the caller on the line keeps them busy and may allow enough time for law enforcement to trace the call. 3. INCORRECT. It is important to document on the hospital Bomb Threat Checklist, but the most immediate action is to keep the caller on the line. 4. INCORRECT. While your initial response may be to run for cover, you should remain calm and not panic, continuing to keep the caller on the line.

A new nurse is preparing an injection from an ampule. What action by the new nurse would require the precepting nurse to intervene? 1. Snaps the neck of the ampule gently towards the body. 2. Uses a filter needle when drawing up the ampule contents. 3. Folds gauze around the ampule neck before snapping open. 4. Avoids touching edges of the ampule when inserting needle.

1. Correct: An ampule is a glass vial with a narrow, scored neck that must be snapped off to open. Even if the neck of the ampule is covered with gauze, the proper procedure is to snap the top away from the body, not toward the body. If the new nurse attempts to snap the top of the ampule toward the body, the charge nurse would need to intervene immediately. 2. Incorrect: This is a correct action. When a glass container is broken, there is the potential for tiny glass shards to fall into the solution and subsequently be infused into the client. To avoid this situation, a filter needle must be utilized to draw up the solution from the ampule. Once drawn up, the filter needle is removed and a regular needle utilized to inject the solution into the client. This is a correct action. 3. Incorrect: The use of an alcohol wipe or small gauze sponge, wrapped around the neck of the ampule prior to snapping the top open is crucial to prevent injury to the nurse. Exposure to the jagged glass top could easily cut a thumb or finger while holding the vial. No intervention needed here. 4. Incorrect: The scenario asks for an incorrect action requiring intervention by the charge nurse. However, this action is appropriate. It is always important to avoid touching the edges of the opened ampule when inserting the needle to prevent possible contamination of the solution.

The nurse tries to notify the primary healthcare provider (PHP) that the dosage of newly prescribed medication is higher than recommended. The PHP cannot be located and the medication is scheduled to be administered in 30 minutes. Which intervention should the nurse implement next? 1. Inform the charge nurse. 2. Administer the medication as prescribed. 3. Document the prescribed medication dosage in the nursing notes. 4. Administer the recommended dosage until the PHP is contacted.

1. Correct: The medication that was prescribed is higher than the recommended dosage. Since the PHP cannot be notified, the charge nurse should be notified to clarify what is the next action for the nurse to initiate. 2. Incorrect: It is beyond the scope of practice for a nurse to independently decide to administer a medication dosage that is higher than recommended. The nurse should not administer the medication. 3. Incorrect: The prescribed medication that is higher than recommended should not be documented in the nursing notes. The medication has not been administered, and the nurse is following the appropriate steps to clarify the dosage of the medication. 4. Incorrect: Client safety is always a priority. It is beyond the scope of practice for a nurse to independently decide to administer a different medication dosage without a prescription from the PHP. The nurse should not administer the medication.

A community health nurse is presenting a seminar to teen parents on the topic of infant safety. What priority topic presented by the nurse represents the leading cause of injury or death among infants? 1. Monitoring the infant for food allergies. 2. Placing the infant in rear-facing, approved car seat. 3. Never propping bottle to feed when infant is alone. 4. Positioning infant prone when sleeping or napping.

2. Correct: The leading cause of death among infants under the age of one year is motor vehicle accidents. When instructing first time or young parents, it is vital to teach the need to have the infant snuggly restrained in an appropriately sized, approved infant car seat in the back seat and rear-facing. 1. Incorrect: While discussing the signs or symptoms of food allergies is an important topic for new parents, this is not the most vital information the nurse could present to the teen parents. 3. Incorrect: An infant should never be left unattended while feeding, and propping a bottle could lead to aspiration or respiratory distress. This is a dangerous practice that needs to be discussed by the nurse; however, there is another topic that is more urgent. 4. Incorrect: The research studies to date indicate the safest sleeping position for newborns and infants is supine, not prone. Positioning is always a nursing concern, and teaching new parents about the potential for sudden infant death syndrome (SIDS) would be crucial. However, another topic presents more important information.

The nurse is caring for a client with multiple episodes of diarrhea and suspected Clostridium Difficile (C. diff). Which interventions should be included in the plan of care? Select all that apply 1. Institute contact precautions only after confirmation of stool culture. 2. Instituting contact precautions for all who enter the client's room 3. Using alcohol based foam for hand hygiene. 4. Dedicating equipment for use only in the client's room. 5. Requesting antidiarrheal medication for the client.

2., & 4. Correct: Contact isolation will be needed to prevent the spread of infection. Also the electronic equipment for vital signs must not be used in the room. The client will need a disposable stethoscope, BP cuff and thermometer dedicated for use in that patient room. 1. Incorrect: Precautions should be instituted and a stool sample sent for any client with persistent diarrhea. Isolation should be in place with suspected c. diff. 3. Incorrect: Soap and water must be used to clean the hands. Alcohol based foams do not have enough alcohol in them to destroy the c diff spores. 5. Incorrect: Medications to stop diarrhea will not be prescribed with c. diff. because they cause even further irritation.

A client diagnosed with human immunodeficiency virus (HIV) is to be sent home today. The nurse has initiated discharge instructions on the proper handling of blood and body fluid at home. The nurse knows the teaching is successful when the client makes what statement? 1. "As long as it's my home, I can use normal cleaning methods." 2. "I must scrub with hot, soapy water and allow it to air dry." 3. "I should clean area with a 10% mixture of bleach and water." 4. "I must sterilize with isopropyl alcohol and rinse with ammonia."

3. CORRECT: The proper method to clean spills of blood or body fluids at home is to use a 10% solution of household bleach, which means 9 parts of water to 1 part bleach. It is recommended to leave the bleach solution on the contaminated area for 10 to 20 minutes, and then rinse with hot water. Any towels or cloths used to clean the area should be double bagged and discarded. 1. INCORRECT: This demonstrates a false sense of security. Even in a home environment, visitors and family could become contaminated with the HIV virus. Microscopic amounts of blood or body fluids could contaminate others, and therefore proper cleaning methods must be followed even at home. 2. INCORRECT: Hot, soapy water will not kill the HIV virus on hard surfaces, regardless of the type of soap or the temperature of the water. Additionally, air drying will not decrease the virulence of the virus. 4. INCORRECT: Isopropyl alcohol, or rubbing alcohol, does not inactivate the HIV virus, even if rinsed with ammonia. Also, mixing household chemical cleaners, such as bleach with ammonia, can create dangerous fumes that are toxic to humans.

The nurse is presenting a seminar to expectant teen parents regarding infant car seat safety. What statement from a teen parent indicates to the nurse that teaching was successful? 1. "It's okay to place the car seat up front as long as it faces backwards." 2. "The baby has to stay rear facing until at least 40 pounds or 40 inches." 3. "Regular seat belts can be used if the child does not like the booster seat." 4. "An infant must stay in the backseat, facing backward, till at least a year old."

4. CORRECT: The nurse is looking for a statement that indicates the teen parents understand the proper use of infant car seats. Although there are some variations from state to state, the National Safety Council advises that infants should be in a rear-facing car seat in the back seat of a vehicle until at least age one year. This comment indicates the parents understand the teaching clearly. 1. INCORRECT: An infant or child car seat can never be placed in the front seat at any time, regardless of what direction it may face. Further teaching is definitely indicated. 2. INCORRECT: A child of 40 pounds or forty inches is of pre-school age, usually around 3 to 4 years old. This is too old for a rear-facing car seat. The issue of height and weight is more useful when determining whether a child can safely move from a car seat to a booster seat. The parents did not understand the instruction. 3. INCORRECT: The choice of booster seat versus regular car seat belts is not based on whether the child likes, or is comfortable, in using either type of restraints. The most accepted guideline for child safety is that children under the age of 8 years old should be in either a child's car seat or booster seat. Further teaching is needed.

A client with diabetes is hospitalized for debridement of a non-healing foot ulcer. Following the procedure, the nurse notes that the client has become confused and combative. The family expresses concern with the behavioral changes and requests that the client be restrained in bed. What is the nurse's priority action? 1. Notify the primary healthcare provider. 2. Apply a vest restraint as requested by family. 3. Move client to a room near the nurse's desk. 4. Obtain a finger-stick blood glucose level.

4. Correct: The client's behavior has negatively changed following the ulcer debridement procedure. The nurse's priority is to determine the cause of the client's confusion. The nurse is correct to investigate other possible causes for the behavior changes, including an abnormal glucose level in this diabetic client. 1. Incorrect: The nurse will indeed have to contact the primary healthcare provider about the client's change in behavior. However, the first priority would be to assess the client and collect data prior to placing that phone call. 2. Incorrect: The nurse understands that restraints cannot be applied by family request. Additionally, applying a restraint can often increase negative behavior while ignoring the actual cause. 3. Incorrect: Although assigning confused clients to a room near the nurses' station is an accepted practice, this does not determine the cause for the changing behavior and is not a priority at this time. The nursing priority is to assess the client for possible factors causing the behavior changes.

A 3 year old child is being treated for asthma. The child weighs 31.5 lb (14.3 kg). The primary healthcare provider has prescribed Albuterol syrup 5 mg PO every 8 hours. What action should the nurse take? Exhibit: Albuterol Classification: Beta 2 Agonist Dosing: 2-6 years: 0.1 mg (0.25 mL)/kg PO q8hr initially, not to exceed 2 mg (5 mL) q8hr; if necessary, may be increased to 0.2 mg/kg PO q8hr, not to exceed 4 mg (10 mL) q8hr 1. Administer the dose immediately to relieve respiratory efforts. 2. Split the dose in two equal parts and administer every 4 hours. 3. Notify the charge nurse that the child needs a different type medication. 4. Notify the primary healthcare provider.

4. Correct: The nurse is responsible for assuring that medications are administered safely. One aspect of safe medication administration is to assure that the prescribed dose is safe for administration. For this age child, the maximum dose that should be administered is 0.2 mg/kg PO every 8 hours. So, we need to determine how much albuterol this child, weighing 14.3 kg can safely have. To calculate this, we would first use the child's weight in this recommended dose formula: The maximum amount is 0.2 mg X 14.3 kg = 2.86 mg every 8 hours. The exhibit also says not to exceed 4 mg every 8 hours, which the prescribed amount exceeds. Remember, the maximum dose based on the individual child's weight is the safest guideline to use. The prescription for this child is to receive 5 mg PO every 8 hours. Is this a safe dose? No! Therefore, the nurse should not administer the medication and should promptly notify the primary healthcare provider. Administering the prescribed dosage could be dangerous to this child! 1. Incorrect: Although this option for administering the dose immediately to relieve respiratory efforts sounds good, could we cause more harm to the client by administering this dose of albuterol? Yes! Relieving respiratory efforts is a goal of therapy, but should be accomplished using safe dosages of the medication. This dose of medication should not be administered. 2. Incorrect: You may have realized that the single dose as prescribed was too much. But would splitting the dose in two equal parts and administering it every 4 hours be safe? No! First of all, the maximum safe dose would still be exceeded. And, as a nurse, it would be out of your scope of practice to alter an existing prescription. 3. Incorrect: What came to your mind when you looked at this? Did you consider if the medication is appropriate for use in a child with asthma? Albuterol acts as a bronchodilator, causing relaxation of the bronchial smooth muscles in the airways and is used to manage asthma and acute bronchospasm. The exhibit provides safe dosing information for a 3 year old child, so it is an appropriate agent for use in this child with asthma. Notifying the charge nurse that the child needs a different type medication would not be appropriate.

During night time rounds, the nurse finds a client has cigarettes in bed and the room is filled with smoke. In what order should the nurse perform the following actions? Remove client from room. Notify hospital operator. Get the fire extinguisher. Close the client's door. Pull the fire alarm handle. Drag and Drop the items from one box to the other

Anytime an internal disaster is suspected, client safety is always the first concern. National Fire Safety codes refer to the mnemonic "R-A-C-E" (rescue -alarm-contain-extinguish). If the area is safe for the nurse to enter, removing the client from that environment would be the first action. Secondly the nurse must activate the EMS alarm system so that emergency personnel are en route. Additionally, the hospital must be alerted by contacting the hospital operator to activate appropriate internal alarm systems. Closing the client's door will help contain any fire or smoke. Finally, the nurse should obtain the closest fire extinguisher appropriate for the type of fire.

A nurse is caring for a group of clients and is considering the risk of infection for each. Place the client conditions in rank order from the highest to least potential for infection. Indwelling foley catheter inserted the previous day Thermal burns covering 30% of body surface area (BSA) 2 days ago Total hip prosthetic device placement 3 days ago Laparoscopic exploration of right knee 2 days ago Drag and Drop the items from one box to the other

The client with the greatest risk of infection would be the client with thermal burns covering 30% of the BSA. Burns are considered contaminated wounds. Normally, skin provides a natural barrier against invasive microorganisms. However, with this major burn injury, the client is predisposed to infection as a result of the loss of skin integrity. Additional factors that will place this client at higher risk for infection include the development of eschar, which bacteria loves to live in, and the fact that thermal injuries alter the body's natural immunity. So, are the clients with the other conditions at risk for infection? Well, they could be, but the risk is not as great. Let's consider why the risk is less. The client with the total hip arthroplasty (replacement of the damaged hip with a prosthetic device implanted) would be the next highest in ranking for risk of infection. This client has a relatively large surgical incision and a prosthetic device that infection, when present, tends to migrate to the area. But, this type surgery is performed using sterile technique in sterile environments to minimize the risk of infection. In addition, any dressing changes should be performed using sterile technique. The next client at risk of infection would be the client with the laparoscopic exploration of the right knee. Again, there is surgical perforation of the skin. However, these are smaller puncture sites that are created under sterile conditions, and when cared for appropriately, do not carry a high risk for infection. Finally, the client who has the indwelling foley catheter is the least at risk for infection. The catheter is a portal of entry into the body, but if inserted using sterile technique and proper catheter care is provided, the risk of infection can be kept to a minimum. The longer the foley catheter remains in place, the risk of infection will increase.

A newly hired nurse has been instructed by the preceptor nurse on burn dressing techniques. The nurse knows teaching has been effective when the new nurse performs wound care in what order? Wash hands and apply clean gloves. Remove the old dressing and discard. Set up sterile field and open packages. Clean burn and place sterile dressing. Wash hands and apply sterile gloves. Medicate client with pain medication. Drag and Drop the items from one box to the other

The correct protocol for changing burn dressings consistently follows a specific pattern. The client must first be medicated for this painful procedure, and at least 30 minutes in advance so the drug has time to work. The nurse must then wash hands thoroughly and apply the clean (non-sterile) gloves. Depending on the type and extent of burns, the nurse may also need a gown to prevent contaminating the client. Although not mentioned here, the nurse would most certainly explain the procedure to the client, which could actually be accomplished while the nurse sets up the sterile field, opens sterile packages and pours the ordered cleansing fluids. Once properly set up, the nurse will gently remove the old dressing and discard along with the non-sterile gloves, per facility protocols. After washing hands a second time, the nurse will apply the sterile gloves to complete care. The burned area is cleaned, prescribed antibiotic cream is applied, and a new sterile dressing placed over the burn.

Following a thyroidectomy, a client reports shortness of breath and neck pressure. Which nursing action is the best response? 1. Remove the dressing and elevate the head of bed. 2. Call a code, open the trach set, and position the client supine. 3. Obtain vital signs. 4. Immediately go to the nurse's station and call the primary healthcare provider.

1. Correct: The nurse should identify that the client is in respiratory distress. So get the dressing off the neck, elevate the HOB and see if they can breathe any better. Stay with the client. 2. Incorrect: Calling a code and opening a trach set is premature. What is likely the problem? Swelling around the airway. Do something that will decrease swelling. Placing the client flat will make the swelling and breathing worse. 3. Incorrect: Don't just look and check. The nurse must do something. This is delaying treatment. Checking the vital signs will not correct the problem. 4. Incorrect: Never leave an unstable client. If the client is having trouble breathing, then that client is unstable. The nurse can call the primary healthcare provider from the room.

A farm worker comes into the clinic reporting headache, dizziness, and muscle twitching after working in the fields. What condition does the nurse suspect? 1. Pesticide exposure 2. Heat stroke 3. Anthrax poisoning 4. Gastroenteritis

1. Correct: These are symptoms of pesticide exposure when combined with the details given of coming from the fields. Death can result from severe acute pesticide poisoning. 2. Incorrect: The data provided does not lead the nurse to suspect heat stroke. The stem does not tell the temperature the farmer is working in. Heat stroke signs and symptoms include increased sweating, tachypnea and temperature greater than 105.8°F (41.0°C). 3. Incorrect: The data provided does not lead the nurse to suspect anthrax poisoning. The worker has been outside in a field. This is not a risk factor for anthrax exposure. Inhalation anthrax develops when you breathe in anthrax spores. It's the most deadly way to contract the disease, and even with treatment it is often fatal. Initial signs and symptoms of inhalation anthrax include: Flu-like symptoms, such as sore throat, mild fever, fatigue and muscle aches, which may last a few hours or days. Mild chest discomfort, Shortness of breath, Nausea, Coughing up blood, Painful swallowing. 4. Incorrect: The data provided does not lead the nurse to suspect gastroenteritis. These signs and symptoms do not go with gastroenteritis. Gastroenteritis signs and symptoms include diarrhea, nausea, vomiting, fever and abdominal cramping.

What should the nurse include in the teaching plan for a client receiving external beam radiation? Select all that apply 1. Small marks will be placed on the skin to mark the treatment area. 2. Lotion may be used around the treatment area to decrease dryness. 3. The radiation therapist can see, hear, and talk with you at all times during treatment. 4. Stay away from babies for 24 hours. 5. You will have to hold your breath during radiation treatment.

1., & 3. Correct: Small ink marks or small tattoos will be placed on the skin to mark the treatment area. Do not remove the marks. The radiation therapist can see, hear, and talk to the client at all times during treatment. Relieve anxiety by letting client know he/she is not alone. 2. Incorrect: The client should avoid the use of potential irritants (perfume, powders or cosmetics) on the skin in the treatment field. 4. Incorrect: The client receiving external beam radiation is not radioactive and will not radiate others. The client can safely be around other people, babies, and children. Clients who are undergoing brachytherapy or receiving radio pharmaceuticals require that you be aware that the client is emitting radioactivity. 5. Incorrect: The client will need to stay very still so radiation goes to the exact same place each time but can breathe as always. The client does not have to hold breath.

A charge nurse is observing a new nurse for proper use of standard precautions for infection control. Which actions indicate that standard precautions are being followed? Select all that apply 1. Wearing clean gloves to convert an IV to a saline loc 2. Donning sterile gloves for a cesarean dressing change 3. Wearing a N95 respirator while caring for a child who has respiratory syncytial virus (RSV) 4. Putting on a gown to take care of a client who has toxoplasmosis 5. Performing hand hygiene after removing gloves

1., 2., & 5. Correct: Clean gloves are needed when there is a chance of coming into contact with blood or body fluids, which is likely to happen when converting an IV to a saline loc. Dressing changes in the hospital are a sterile procedure and require the use of sterile gloves. Hand hygiene should be performed before and after contact with a client immediately after touching blood, body fluid, non-intact skin, mucous membranes, or contaminated items. It should also be performed after removing gloves, before eating, and after using the restroom. 3. Incorrect:The N95 respirator is used with airborne precautions and RSV requires droplet precautions. 4. Incorrect: Toxoplasmosis is transmitted through the feces of infected cats or through ingestion of raw or rare meats. A gown is not required in the care of this client because transmission occurs through ingestion of the parasites.

The home health nurse is assessing the home environment for threats to the safety of the toddler who lives in the home. Which observations should be included in this assessment? Select all that apply 1. Do stairs have guard gates? 2. Are safety covers on electrical outlet plugs? 3. Is the swimming pool inaccessible to the toddler? 4. Are cleaning supplies located out of the toddler's reach? 5. Are stairs brightly lit?

1., 2., 3. & 4. Correct: Toddlers may fall if left unsupervised around stairs. Make sure that gates are in place and that they are used. Toddlers are at risk for exploring the outlets by putting metal objects into the outlets or putting their fingers in them. They should be covered unless in use. Toddlers can drown in small amounts of water and they may try to explore swimming pools if they are accessible. Pools should have fences or locking stairs and the child should never be left unsupervised around the pool. Toddlers are curious and may get into cabinets containing harmful substances. 5. Incorrect: This assessment would be important for the visually impaired or elderly, but not specifically for toddlers. The guard gates should be in place so that the toddler does not have access to the stairs.

The nurse is monitoring the infection risk in a client that is to begin chemotherapy. Which activity should alert the nurse that the client is at a higher risk for infection? Select all that apply 1. Enjoys getting manicures and pedicures every two weeks. 2. Loves to go with the children to the local water park. 3. Relaxes in hot tubs when traveling. 4. Selects steamed vegetables as part of routine dietary intake. 5. Prefers to go barefooted when at home. 6. Keeps cats in the home and cleans the litter boxes once a week.

1., 2., 3., 5., & 6. Correct: Infection is one of the most common life-threatening complications associated with cancer and chemotherapy. You know that both the cancer and chemotherapy weakens the immune system. Therefore, clients on chemotherapy should be familiar with activities that should be avoided due to the risk of infection with the immunosuppressed state. There are several things that are known to increase the risk of infection in these clients. Did you pick up on these? Well, let's look at a few of these. Clients on chemo should not get manicures or pedicures at salons or spas and should avoid having false nails or nail tips applied. There is too great a risk of contamination at the public salons, so clients are encourage to use their own personal and well-cleaned tools for nail care at home. Another source of bacterial contamination is public water parks. Although these parks take measures to reduce the risk of infection to the general public, the risk is too great for a client on chemo. Swimming can result in accidental ingestion of water which increases the risk of cryptosporidium or other waterborne pathogens. Same thing applies to hot tubs. ​So why is going barefoot at home such a big deal? Well, this increases the risk of cuts, scrapes, or other injury that would increase the portal for infectious agents to enter. In addition, the exposure to potential infectious agents is greater. The oncologist may direct the client in the best way to deal with this client having cats in the home and cleaning the litter box due to the risk of exposure to bacteria and parasites. If allowed to clean the litter box, latex or rubber gloves, along with a mask over the nose and mouth is generally recommended to reduce the risk of infection. In addition, the client should be instructed to thoroughly wash the hands with soap and water after cleaning the litter box or after touching the cats. 4. Incorrect: Although the intake of fresh fruits and vegetables has been controversial, most agree that if washed properly, even fresh fruits and vegetables can be consumed. However, the oncologist should be the one to approve the dietary intake of these. Here, we have vegetables that have not only been washed, but steamed as well. These should be safe for consumption for clients on chemo.

The homecare nurse is providing family teaching on safety issues for a client diagnosed with Parkinson's disease. What adaptations should the nurse instruct the family to initiate? Select all that apply 1. Install grab bars on tub walls. 2. Place nightlights in hallways. 3. Add bran and fiber to daily diet. 4. Remove scatter rugs or loose cords. 5. Keep bedroom dark, cool and quiet. 6. Put tennis balls on legs of walker.

1., 2., 3., 4., & 5. Correct: Parkinson's disease causes deterioration of the basal ganglia, ultimately impacting motor control and function. As muscles become stiff and rigid, mobility slows, resulting in poor coordination and loss of balance. Safety is a chief concern in all ADLs, requiring modifications in activity, nutrition, and the client's environment. Because Parkinson's disease affects mobility, modification such as grab bars and night lights are essential. Clients develop constipation because of decreased peristalsis, so adding bran and fiber can address impending bowel issues. Scatter, or throw, rugs along with loose extension cords on the floor create a fall risk because the client is unable to pick up feet during ambulation. The shuffling gait that develops increases the risk for falls. These clients also have problems with insomnia along with poor REM sleep, leading to daytime drowsiness. Making the bedroom conducive to sleep may help alleviate symptoms for a period of time. A dark, cool room with no distractions is the most appropriate sleep environment. 6. Incorrect: The proper method of utilizing a walker is to step into the walker, pause and then move it forward before stepping again. Even though clients with Parkinson's disease have a shuffling gait and stooped posture, sliding a walker with tennis balls on the walker legs presents a serious safety issue. The client would not have the ability to control the speed or hold the walker steady while stepping into it.

A nurse works in the operating room (OR) as a circulator. Which actions should the nurse perform to help prevent surgical-site infections? Select all that apply 1. Keep the OR doors closed during a surgical case. 2. Minimize traffic in the OR. 3. Ensure the room has negative air flow. 4. Monitor the sterile field at all times. 5. Immediately discard any object that becomes contaminated.

1., 2., 4. & 5. Correct: Positive pressure can be used in rooms adjacent to a negative pressure room. The purpose of positive pressure is to ensure that airborne pathogens do not contaminate the patient or supplies in that room. Positive pressure could be used in an operating room to protect the patient and sterile medical and surgical supplies. Positively pressurized rooms are typically considered the cleanest rooms in the hospital. Keeping the doors open impedes the air exchange system in the OR. The air exchange system is designed to decrease airborne contaminants in the OR. Limiting the traffic in the room decreases the amount of bacterial shedding, minimizes harmful air turbulence, and prevents accidental contamination of the sterile field. Contaminated objects break sterile field. 3. Incorrect: Negative air flow has not been proven to prevent surgical-site infections. Negative air flow refers to an airborne infection isolation room. A negative pressure room in a hospital is used to contain airborne contaminants within the room. Harmful airborne pathogens including bacteria, viruses, fungi, yeasts, molds, pollens, gases, VOC's (volatile organic compounds), small particles and chemicals are part of a larger list of airborne pathogens you can find in a hospital. A negative pressure isolation room is commonly used for clients with airborne infections. For example, a client with active tuberculosis, a disease caused by the bacteria Mycobacterium tuberculosis, will be placed in a negatively pressurized room because the tuberculosis bacterium is spread in the air from one person to another. When the client with active tuberculosis sneezes or coughs, other people may become infected when they inhale. However, by using a negative pressure room you can better contain the bacterium within the room.

Which nursing action represents measures taken to protect the client from a mode of infection transmission in the chain of infection? Select all that apply 1. Donning personal protection equipment. 2. Administering the Haemophilus influenzae type B (HIB) immunization to a child. 3. Disposing of soiled gloves in the appropriate receptacle. 4. Wearing gloves when coming into contact with client's secretions. 5. Teaching importance of long pants and sleeves and insect repellent to reduce the risk of West Nile Virus. 6. Performing hand hygiene after removal of soiled gloves.

1., 3., 4., & 6. Correct: In this question, can you identify the nursing actions that represent prevention of the spread of infection to other clients at the point of mode of transmission on the chain of infection? The first one identified is the donning of personal protection equipment. This prevents the infectious agent from coming into contact with the nurse's hands that could then spread the infection to other clients. Next, disposing of soiled gloves in the appropriate receptacle assures that the infectious agents are not carried outside of the infectious client's room and then transmitted to other clients. Gloves should always be worn when there is a possibility that the nurse could come into contact with the client's secretions. Hand hygiene is a crucial part of infection control. Hand hygiene by washing the hands and/or using alcohol based sanitizer before and after glove removal reduces the risk of the spread of infection. Both the use of gloves when secretions are present and proper hand hygiene help to prevent the nurse's hands from becoming a mode of infection transmission to other clients. 2. Incorrect: Immunization of a child against Haemophilus influenzae type B (HIB) is an example of a nursing action to prevent infection transmission by disrupting the susceptible host link in the chain of infection. This is accomplished by increasing the resistance of the host to the infectious agent, which in this case is HIB. 5. Incorrect: Teaching clients about the importance of wearing long pants and long sleeves, as well as using insect repellent is an example of nursing action aimed at reducing the risk of West Nile Virus by breaking the chain of infection at the portal of entry link. By wearing the protective clothing and using insect repellent, the vector (mode of transmission) is not as likely to be able to access a portal of entry on the host.

The nurse is preparing a client for transport to the radiology department for a left lung tissue biopsy. Which actions should the nurse make certain have been completed? Select all that apply 1. The consent form is signed. 2. The operative site is prepped with a razor. 3. The most recent lab work is on the chart. 4. Any preoperative medication is given as prescribed. 5. Person performing the procedure has marked the site.

1., 3., 4. & 5. Correct: The nurse should ensure that the consent form is signed, the lab work is in order, and any prescribed preoperative medication is given. The operative site is marked by the person who is ultimately accountable for the procedure and will be present when the procedure is performed. 2. Incorrect: The site should be prepped with clippers as opposed to a razor, which can cause injury to the client. The goal of preoperative skin preparation is to decrease bacteria without injuring the skin.

Which discussion points should a nurse plan to include when teaching a group of college students on prevention of sexually transmitted infections (STI)? Select all that apply 1. Safe sex practices 2. Routine human immunodeficiency virus (HIV) testing 3. Proper use of birth control pills 4. Sexual abstinence 5. Vaccinations for STIs

1., 4. & 5. Correct: All of these topics should be included when discussing prevention of STIs. Safe sex practices include proper use of condoms. Abstinence is the best way to prevent STIs. Vaccines are available for some STIs such as human papillomavirus vaccine (HPV). 2. Incorrect: Routine HIV testing is not a way to prevent HIV or other STIs. It will provide early diagnosis. The best course of action is to prevent occurrence. 3. Incorrect: Birth control pills help prevent unplanned pregnancy. STIs can still be contracted if proper safe sex techniques are not implemented.

In which situations should the nurse notify the primary healthcare provider of a medication incident? Select all that apply 1. Every occurrence. 2. Client is harmed or dies. 3. Medication incident is a near miss. 4. Nurse administers an incorrect dosage. 5. Client questions the medication color.

2. & 4. Correct: The primary healthcare provider should be notified if harm is brought to the client or death occurs as a result of the medication incident. The primary healthcare provider should be notified if the nurse administers an incorrect dosage to the client, and an incident report needs to be completed in this situation. 1. Incorrect: The primary healthcare provider should be notified if harm is brought to the client but not for all events with medications. An incident report should be completed so the hospital can track incident patterns for quality improvement. 3. Incorrect: Near misses do not need to be reported to the primary healthcare provider. Following the rights of medication administration every time ensures medication error prevention. 5. Incorrect: The nurse should answer questions regarding medication color. Depending on the manufacturer, the shape and color of the medication can vary.

While preparing to administer intravenous of chemotherapy the nurse accidently pulls the tubing apart, spilling the solution onto the floor. After clamping the tubing, what is the nurse's immediate action? 1. Use disposable towels to clean up the liquid. 2. Obtain spill kit specific to this type of solution. 3. Complete an incident report for supervisor. 4. Call housekeeping to help clean up the floor.

2. CORRECT: Chemotherapy spill kits are pre-packaged supplies specific to the type of cytotoxic drugs used and are kept in close proximity to the location the chemo is administered. These kits vary slightly but all follow the basic guidelines. Individuals cleaning up the spill must be completely covered head to toe to prevent any contact with the drug. This includes inhalation. This option contains the word solution, which also appears in the question. 1. INCORRECT: Disposable towels are not acceptable to clean up a chemotherapy spill. Although these towels are absorbent for kitchens and bathrooms, only special absorbent pads can be used to clean up cytotoxic drugs. 3. INCORRECT: While it is true that the nurse will need to complete an incident report regarding the chemotherapy spill, it is certainly not the nurse's immediate action. Focus on staff and client safety first. 4. INCORRECT: The responsibility for cleaning up cytotoxic drugs is for the nursing staff involved at the time. Special training and knowledge is required to handle this issue.

The charge nurse is observing a nurse perform a dressing change on a client with a Stage III pressure ulcer. What observation by the charge nurse would indicate a need for further teaching? 1. Irrigates the pressure ulcer with 50 mL normal saline. 2. Irrigates the pressure ulcer with half-strength hydrogen peroxide. 3. Packs the wound with sterile gauze soaked in normal saline. 4. Applies a hydrocolloid dressing over the wound after cleansing.

2. Correct: Pressure ulcers should not be cleaned with substances that are cytotoxic such as hydrogen peroxide, betadine or Dakin's solution. Cytotoxic means toxic to cells, or cell-killing. Any agent or process that kills cells. These solutions can kill or damage cells, especially fibroblasts. Dakin's solution is a type of hydrochlorite solution. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine is the active ingredient in Dakin's solution. 1. Incorrect: Normal saline is an appropriate solution and is used to clean pressure ulcers. This does not kill or damage cells. 3. Incorrect: Normal saline is an appropriate solution and pressure ulcers may be packed with sterile gauze. This helps remove necrotic tissue. 4. Incorrect: The wound should be covered with an appropriate dressing after cleaning. Hydrocolloid dressings support healing in clean granulating wounds and autolytically debride necrotic wounds. Hydrocolloid dressings are occlusive, so they provide a moist healing environment, autolytic debridement, and insulation.

The following clients arrive to the emergency department (ED) at the same time. The triage nurse gives priority to which client? 1. A client with a possible fracture of the tibia 45 minutes ago. 2. A client with left hemiparesis and aphasia beginning 1 hour ago. 3. A client smelling of alcohol and reporting of severe abdominal pain. 4. A client involved in a motor vehicle accident (MVA) with a possible fractured pelvis.

2. Correct: The client who is started experiencing hemiparesis and aphasia 1 hour ago is likely having a stroke. The window for treatment with fibrinolytics is 3 hours, thus taking priority over the other clients. Time is brain! 1. Incorrect: This client has a possible fracture of the tibia. This is not a large bone, which would be at risk for hemorrhage. Splinting and ice packs could be used until after seeing the client having a stroke. 3. Incorrect: With this client, you would worry about pancreatitis. This client needs to be seen soon but not prior to the client having a stroke. 4. Incorrect: The MVA client could have bleeding from a fractured pelvis. This client is high on the admit list, but after the client having a stroke.

A client has been admitted with multiple severe allergies, including food and medications. The nurse knows what actions are most important to protect the client? Select all that apply 1. Assign client to a private, sterile room. 2. Place allergy alert bracelet on client. 3. Have client wear mask when in hallway. 4. Attach sign listing allergies above the bed. 5. Send list of allergies to dietary department.

2., & 5. CORRECT: It is crucial to place the facility's allergy alert bracelet on the client upon admission, generally on the same wrist as the facility ID bracelet. Each time the client's ID is verified, staff will also see the allergy bracelet. Dietary department must also be alerted of all allergies in writing as should the pharmacy. In most facilities allergy alert stickers are attached on the outside of the chart, on the medication sheet, and facility-specific areas to remind the staff caring for the client. 1. INCORRECT: A client with allergies does not have to be placed into a private room, even if the allergies are environmental. There is no such thing as a "sterile" client room, which implies a sealed location with reverse airflow system. Although operating rooms try to maintain a sterile atmosphere, the entire room itself is not sterile. 3. INCORRECT: Allergies would not require the client to wear a mask in the hallway, or when transported to another department. Even if a client allergy is airborne, such as dust, a mask does not provide significant protection. 4. INCORRECT: A sign listing exact client allergies would violate HIPAA regulations and privacy policies. In severe cases, a facility may choose to place a plain allergy sticker in the client's room, but cannot place any specific, identifying client information in public view.

The nurse is assisting a client with right-sided weakness to transfer from the hospital bed to a wheelchair. The client has an IV attached to an IV pole on the right side of the bed. How should the nurse complete this transfer? Select all that apply 1. Place the wheelchair on the left side of the bed. 2. Place the wheelchair on the right side of the bed. 3. Face the wheelchair toward the foot of the bed. 4. Face the wheelchair toward the head of the bed. 5. Have client grab the wheelchair with the right arm. 6. Have client grab the wheelchair with the left arm.

2., 4., & 6. Correct: The wheelchair should be placed on the right side of the bed where the equipment is located. It needs to face the head of the bed so the client can reach the chair with the strong left arm to help with the transfer. The client should grab the wheelchair arm with the strong left arm. 1. Incorrect: Since the IV and IV pole are on the right side of the bed, the wheelchair should be placed on the right side rather than the left side of the bed. There would not be enough slack in the IV tubing to get out on the left side. 3. Incorrect: If the wheelchair faces the foot of the bed, then the client would not be able to reach with the wheelchair arm with the strong left arm. The client needs to be able to use the left arm for stability. 5. Incorrect: The client should grab the wheelchair arm with the strong left arm. The right side is weak and grabbing with this side puts the client at an increased risk for falls and injury.

The nurse is caring for a client undergoing electroconvulsive therapy (ECT) for major depression. What is the nurse's most important intervention during the treatment? 1. Monitor vital signs and cardiac functioning. 2. Provide support to the client's arms and legs. 3. Provide suctioning as needed. 4. Place electrodes on temples.

3. Correct: Ensuring patency of the airway is the nurse's first priority. The client should also be NPO for 6-8 hours prior to the procedure. 1. Incorrect: This is an intervention, but does not come before airway. Vital signs do need to be monitored but the client's breathing is a higher priority. 2. Incorrect: This is an intervention, but does not come before airway. Support the extremities due to the seizure activity but highest priority remains airway. 4. Incorrect: This is done prior to initiation of the procedure to deliver the electrical stimulation. The question asks for the most important intervention during the treatment.

A client is brought to the emergency room following a serious motor vehicle accident. Standing orders include initiating an IV line and inserting a foley catheter. What action should the nurse take first? 1. Obtain all supplies for the procedures. 2. Explain the procedure to the client. 3. Check the client's identification band. 4. Verify client has signed consent forms.

3. Correct: Even in an emergency, the nurse follows the nursing process by initially gathering data, including identifying the client before beginning any ordered interventions. The client's identity must always be verified before any procedure or treatment. 1. Incorrect: It is important to make sure all necessary supplies are present before beginning an intervention. Stopping in the middle of a procedure to get supplies could expose the client to infection or other complications. However, gathering supplies is an action, which is not the first step when providing care to any client. 2. Incorrect: While it is important to explain any procedure to the client, the scenario does not indicate if this client is even conscious. The nurse has another important priority. 4. Incorrect: When stabilizing an injured client, consent is implied for life-saving procedures such as initiating an IV or applying oxygen. Additionally, obtaining or verifying consent is not a nursing responsibility.

A school nurse is caring for a child who fell on the playground. Upon examination of the child, the nurse notes multiple bruises in various stages of healing. What is the nurse's initial intervention? 1. Ask the parents who hit the child on the back. 2. Notify the child's primary healthcare provider. 3. Contact the Department of Health and Human Services. 4. Document the findings and observe the child over the next week.

3. Correct: Unless there is a policy to direct otherwise, the nurse who suspects child abuse is obligated to report it to the Department of Health and Human Services (DHS). 1. Incorrect: This is confrontational and will warn the parents that you suspect abuse. This may lead to greater harm for the child. 2. Incorrect: Unless there is a policy to direct otherwise, the nurse who suspects child abuse is obligated to report it to the Department of Health and Human Services. DHS, rather than the primary healthcare provider can intervene to maintain the child's safety. 4. Incorrect: This is delaying care. If the child is being abused, not reporting it could lead to serious injury or even death.

The nurse discovers that a client was given the wrong medication. After verifying the client is stable, an incident report is completed. What is the proper disposition of the report? 1. Send a copy of the report to the primary healthcare provider. 2. Notify the State Board of Nursing about the incident report. 3. Document that a report was completed on the client's chart. 4. Give the report to the hospital's risk management team.

4. Corect: The purpose of an incident report is to describe and document a particular event, injury, medication error, or other occurrence that affects a client or staff member. This report is then sent directly to the hospital risk management team for the express purpose of developing a plan or protocols to prevent a repeat occurrence. 1. Incorrect: Although the primary healthcare provider will need to be informed of the medication error and the client's current status, including vital signs, a copy of the incident report is not provided. 2. Incorrect: The State Board of Nursing is rarely notified about medication errors or the existence of an incident report. 3. Incorrect: The information documented on the main chart includes the client's current status and assessment specifics. It should also be documented that the primary healthcare provider was notified. However, there should not be any mention of the incident report on the client's chart.

A client is admitted with irritable bowel syndrome (IBS) and shingles. The nurse is discussing the client assignments with the charge nurse. Which staff member should not be assigned to this client? 1. The nurse with a history of roseola. 2. The unlicensed assistive personnel (UAP) with no history of roseola. 3. The UAP with a history of chickenpox. 4. The LPN/LVN with no history of chickenpox.

4. Correct: A nurse who has not had chickenpox could contract it and should not be assigned a client with shingles. Those who have not developed antibodies to the varicella zoster virus are susceptible to chickenpox. Chicken pox and shingles are both from the varicella virus. 1. Incorrect: Roseola is a rose colored rash and would not have any effect on the assignment. It is a generally mild infection that usually affects children by age 2, and rarely adults. It is caused by 2 strains of herpes virus, rather than the varicella virus. 2. Incorrect: Roseola is a rose colored rash and would not have any effect on the assignment. It is a generally mild infection that usually affects children by age 2, and occasionally adults. It is caused by 2 strains of herpes virus, rather than the varicella virus. There is no relationship between roseola and shingles. 3. Incorrect: Shingles is caused by a reactivation of the varicella-zoster virus (which causes chicken pox). Those who have not developed antibodies to the varicella-zoster virus are susceptible to chickenpox. Therefore, the UAP who had chicken pox could be assigned this client.

A client with cervical cancer received an internal cervical radiation implant. What should be the initial nursing action if the radiation implant becomes dislodged and is found lying in the bed? 1. Call the client's primary healthcare provider. 2. Pick up the implant immediately with gloved hands and place it in double biohazard bags. 3. Notify the radiology department. 4. Utilize long-handled forceps to pick up the implant and dispose of it in a lead container.

4. Correct: If a client is receiving a radiation implant, a lead container and long-handled forceps should be placed in the client's room and kept for the duration of the therapy. If the implant becomes dislodged, the nurse should pick up the implant with long-handled forceps and place it in the lead container. 1. Incorrect: The placement of the implant into the lead container should be done initially. The primary healthcare provider may be notified but this is not the initial nursing action needed. 2. The implant should be picked up with long forceps for distance and reduction of contact. In addition, a biohazard bag is not sufficient for proper disposal of the radiation implant. 3. The initial action is to use long-handled forceps and dispose of the implant in a lead container. Calling the radiology department is delaying care and exposing individuals to the implant.

A nurse enters a client's room to find the client on the floor having a seizure. Which nursing action is appropriate for this client? 1. Hold the client's arms and legs. 2. Insert a padded tongue blade in the client's mouth. 3. Assist the client back into the bed. 4. Place a rolled towel under the client's head.

4. Correct: Placing a rolled towel under the client's head prevents further injury to the client. 1. Incorrect: Restraining the client may cause further injury to the client. 2. Incorrect: Forcing an object into the client's mouth can result in choking the client or injuring the client's teeth and mouth. 3. Incorrect: Lifting the client may cause injury to the nurse and client.

While preparing an information sheet for a client diagnosed with a vancomycin-resistant enterococcus (VRE) urinary tract infection (UTI), the home health nurse should include which instructions? 1. Wash hands with hot water and soap when hands are soiled. 2. Gloves are not needed in the home since contamination with VRE has already occurred. 3. Wash hands before using the bathroom and after preparing food. 4. Clean the bathroom and kitchen with warm water and bleach.

4. Correct: The bathroom and kitchen should be cleaned with warm water and bleach to decrease contamination. The client should wash hands after using the bathroom and before preparing food. 1. Incorrect: Instructing the client and family to wash with hot water can cause drying and cracking of the skin. Hands should be washed with all contacts. Washing hands is the single most important thing to do to prevent infection. 2. Incorrect: Gloves are needed with VRE to prevent spread of infection. Gloves are especially needed if contact with blood or other infectious materials is anticipated. 3. Incorrect: Hands should be washed after using the bathroom and prior to handling or preparing food.

The nurse notices the primary healthcare provider removes gloves after performing an invasive procedure on a client. The healthcare provider then enters another client's room without washing hands. What is the initial action by the nurse? 1. Ignore it since the primary healthcare provider knows best. 2. Contact the nursing supervisor. 3. Notify the chief of medical staff. 4. Remind the primary healthcare provider of the importance of standard precautions.

4. Correct: The nurse is the client's advocate and can remind the primary healthcare provider of the importance of washing hands before entering a client's room. Hand washing should be performed when going from one room to another. 1. Incorrect: Nurses are to be client advocates and resolve a problem that they see. The primary healthcare provider should wash their hands prior to entering another client's room. 2. Incorrect: The nursing supervisor is not the first step, the nurse is. This incident may be reported to the charge nurse at a later time but the client's safety is priority. 3. Incorrect: This is not the first step. The nurse should address the problem when it is witnessed. The nurse should follow the chain of command when reporting a problem but speaking to the chief of medical staff is not the best action at this time.