NCLEX safety

The client with tuberculosis is to be discharged home with nursing follow-up. Which aspect of nursing care will have the highest priority?

teaching the client about the disease and its treatment;

Which action by the nursing assistant would require immediate intervention by the nurse?

restraining a school-age child at risk for self-harm because the nursing assistant had to leave the room

In developing a security plan for a pediatric unit, a nurse must consider which factors? Select all that apply.

identification of neonates, infants, toddlers, children, and adolescents at all times available resources to obtain and maintain the security plan the facility's physical layout methods for educating all staff regarding the security plan

A client is being admitted to the hospital with abdominal pain, anemia, and bloody stools. The client complains of feeling weak and dizzy. The client has rectal pressure and needs to urinate and move their bowels. The nurse should help the client

onto the bedpan.

A nurse preparing to discharge a child with leukemia observes a family member who has a cold sharing a meal with the child. How should the nurse approach the situation?

Offer a face mask to the person with the cold and use this as an opportunity for further teaching.

The nurse is administering oxycodone for leg pain, as requested by the client. What priority actions will the nurse implement? Select all that apply.

Verify the healthcare provider's order. Assess the client for allergies. Assess the client's respirations. Identify the client.

The nurse empties a Jackson-Pratt drainage bulb. Which nursing action ensures correct functioning of the drain?

compressing it and then plugging it to establish suction

A nurse is caring for a client with a fresh postoperative wound following a femoral-popliteal revascularization procedure. The nurse fails to routinely assess the pedal pulses on the affected leg, and missed the warning sign that the blood vessel was becoming occluded. The nurse manager is made aware of the complication and the nurse's failure to assess the client properly. What action should be taken by the nurse manager?

Address the nurse's omissions as negligent behavior.

A biohazardous trash container is placed outside of a client's room. Which item should the nurse place in this container? Select all that apply.

liquid blood semiliquid blood dressing with blood dressing with purulent drainage

The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for the unit's clients during a fire alarm?

Close all of the doors on the unit.

A nurse is leading a group of parents of toddlers in a discussion on home safety. The nurse should share what information about the most common cause of toddler deaths?

accidents

After administering an I.M. injection, a nurse should

discard the uncapped needle and syringe in a puncture-proof container; The appropriate procedure is to discard uncapped needles in a puncture-proof, leak-proof container. To reduce the risk of accidental needle sticks, the nurse should never recap a needle. The nurse should never place a used needle in a garbage can or in a medical waste container that isn't puncture-proof and leak-proof. The nurse should never break or bend a needle before discarding it. Doing so increases the risk of a needle stick.

A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature?

every 15 minutes

Which prescription is entered correctly on the medical record?

fentanyl 50 mcg given IV every 2 hours as needed for pain greater than 6/10

A nurse is teaching the proper use of crutches to a school-age child with a femur fracture with no weight bearing. What will the nurse include with teaching about walking with crutches?

"After advancing both crutches the length of one step, move your 'good' leg forward."

A charge nurse learns of another nurse who has had two unsuccessful attempts at starting a peripheral IV for a child. What is the most appropriate action by the charge nurse?

Speak to the nurse about the situation and offer to start the child's IV; When starting a peripheral IV for a child, no more than two attempts at insertion should be made by one nurse. Therefore, the charge nurse should interrupt the nurse and offer to start the IV. In children, total attempts at IV insertion should be limited to four because multiple unsuccessful attempts cause the child unnecessary pain, delay treatment, and increase the risk of complications.

The nurse on a gerontology unit will be admitting several new clients to the unit over the next few hours. There are two shared rooms and one single-client room currently vacant on the unit. Which client should be placed in the single-client room?

a client who has developed hypokalemia due to Clostridium difficile-related diarrhea

The nurse is teaching a client how to self-administer epinephrine using an EpiPen autoinjector. What information should be included in the teaching? Select all that apply.

After administering the injection, massage the area for 10 seconds. Hold the EpiPen autoinjector against the thigh for 10 seconds. Jab the EpiPen autoinjector firmly into the outer thigh.

A school-age child is admitted to the medical facility with a diagnosis of acute lymphocytic leukemia (ALL). Which nursing interventions are most appropriate?

washing hands before/upon entering room; Both ALL and its treatment cause immunosuppression. Therefore, thorough hand washing is the single most effective way to prevent infection in an immunosuppressed client. Reverse isolation does not significantly reduce the incidence of infection in immunosuppressed clients; furthermore, isolation may cause psychological stress. The client does not need to wear a mask when in their room. Instead of limiting the number of visitors to the client, the nurse should keep persons with known infections out of the client's room.

The nurse is admitting a client with glaucoma. The client brings prescribed eye drops from home and insists on using them in the hospital. What should the nurse do?

Explain to the client that the health care provider (HCP) will write a prescription for the eye drops to be used at the hospital.

A nurse is supervising a new graduate registered nurse who is caring for a client hospitalized with active tuberculosis (TB). Which action by the new graduate requires the nurse to intervene?

A surgical face mask is applied before entering the client's room;A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the client's room because the HEPA mask can filter out 100% of small airborne particles.

Which situations should a supervisor consider in making assignments for nurses in the neonatal unit?

A pregnant nurse shouldn't care for a neonate with cytomegalovirus (CMV); CMV exposure can affect the fetus; women who are pregnant should avoid contact with CMV-positive clients.

A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa, throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary importance?

Demonstrating control over aggressive behavior

A client recovering from a stroke has slid down in bed and needs to be repositioned. Which action should the nurse take to ensure safety for both the client and the nurse?

Ask for assistance from the lift team; A safe and effective approach to client repositioning is the use of a lift team. When using a team, a group of care providers share the weight of the client, reducing the risk of personal injury, and providing a safe method of repositioning the client.

At the beginning of a shift, the team leader notices that all of the I.V. antibiotics for a client are still in the medication room. What is the team leader's first action?

Ask the nurse assigned to this client about the medications.

While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. In which order of priority from first to last should the nurse take the actions?

Assess the client's current condition and vital signs. If no acute injury, get help, and carefully assist the client back to bed. Notify the client's health care provider (HCP) and family. Document as required by the facility.

A nurse assesses a client with psychotic symptoms and determines that the client likely poses a safety threat and needs vest restraints. The client is adamantly opposed to this. What would be the best nursing action?

Contact the physician and obtain necessary orders.

A nurse working in the emergency department is concerned that a client, who is in police custody, is handcuffed to the stretcher. The nurse asks the police officer to remove the cuffs, but the officer refuses. What should be the next action by the nurse?

Continue to assess the client, allowing the officer to assume responsibility for the handcuffs.

A parent calls the health clinic and tells the nurse that the toddler was found with an open and empty bottle of acetaminophen. The parent asks the nurse what to do. What is the nurse's priority intervention?

Give the parent instructions on how to call poison control;

Which activity should a nurse recommend to prevent foreign body aspiration in a child during meals?

Insist that the child remain seated while eating.

The nurse is caring for a toddler who is visually impaired. What is the most important action for the nurse to take to ensure the safety of the child?

Maintain a tidy environment around the child.

The nurse from the previous shift identified a client as a high risk for falls. The oncoming nurse finds the client on the floor at the beginning of the shift. The nurse assesses the client and notes no injuries. What is the best action by the nurse?

Notify the health care provider, and document the fall in the chart, including location, injuries, the fact the health care provider was notified, and any changes to the care plan; If an injury was present the client should remain where the fall occurred; however, if no injuries are noted the client should be assisted off the floor. The nurse should not include information that places blame on other health care members. The fall must be reported even if the client does not suffer an injury. Documentation of the incident in the client's chart is required.

The nurse received an order to administer intravenous fluids with potassium for a client receiving intravenous fluids. What step(s) are included in the process? Select all that apply.

Review the client's laboratory values. Obtain correct ordered intravenous fluids. Identify client with two methods. Review the label of the intravenous tubing.

The nurse administers an antipsychotic drug to a client with acute mania. The client still refuses to lie down on her bed, pushes other clients in the hallways, and screams threatening remarks to the staff. What should the nurse do next?

Seclude the client and use restraints if necessary.

An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. What should the nurse advise the mother to do?

Remove any unsafe items from the area in which the infant is mobile.

A neonate is experiencing respiratory distress and is using a neonatal oxygen mask. An unlicensed assistive personnel has positioned the oxygen mask as shown. The nurse is assessing the neonate and determines that the mask:

The mask is appropriate because it covers the nose and mouth and fits snugly against the cheeks and chin. The mask is not too low. Masks that are too large may cover the eyes. Masks that are too small obstruct the nose.

A medication order reads, "Meperidine 1 ml I.M. stat." A nurse responsible for administering the drug should base the next action on which understanding?

The nurse should clarify the order with the physician; The nurse must clarify this order with the physician because meperidine is available in several dosage strengths, and 1 ml may contain varying amounts of the drug. A stat order need not specify a precise administration time. Meperidine is commonly given I.M. Because the order specifies the drug volume but not the dosage, the nurse shouldn't consider this order correct and valid.

After the spouse has visited, a client begins crying and saying that the spouse is a mean person. When the client starts pounding on the overbed table and using incomprehensible language, the nurse feels incapable of handling the situation. What should the nurse do at this time?

Use the call system to request assistance; A nurse who feels unable to handle a problem should use the call system to seek assistance. The nurse should stay with the client until help arrives, unless the nurse feels that personal harm is imminent. Telling the client the spouse is under stress and instructing the client not to pound the table are inappropriate because they're nontherapeutic responses; they don't address the client's feelings or needs. Informing facility security is an overreaction to the situation at this point.

A client with cervical cancer is undergoing internal radium implant therapy. A lead-lined container and a pair of long forceps have been placed in the client's hospital room. What should the nurse tell the client about how these will be used? The forceps and container will be used for:

handling of the dislodged radiation source; Dislodged radioactive materials should not be touched with bare or gloved hands. Forceps are used to place the material in the lead-lined container, which shields the radiation. Exposure to radiation can occur only by direct exposure to the encased radioactive substance; it cannot result from contact with emesis or urine or from touching the client. Disposal of eating utensils cannot lead to radiation exposure. Radioactive dose materials are kept only in the radiation department

A nurse on a night shift entered an elderly client's room during a scheduled check and discovered the client on the floor beside the bed after falling when trying to ambulate to the washroom. After assessing and assisting the client back to bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?

identifying risks and ensuring future safety for clients

According to hospital protocol, after a client is restrained, the staff meet and discuss the restraint situation. In addition to sharing feelings and offering support, what should the nurse identify as the long-term goal for the debriefing?

improving the staff's use of restraint procedures

A 15-year-old adolescent confides in the nurse that the adolescent has been contemplating suicide. The adolescent has developed a specific plan to carry it out and pleads with the nurse not to tell anyone. What is the nurse's best response?

"For your protection, I can't keep this secret. After I notify the physician, we will need to involve your family. We want you to be safe."

A nurse is preparing to perform a physical examination on a postpartum client. The client asks the nurse why gloves are necessary for the examination. What is the nurse's best response?

"Gloves are required for standard precautions."

When assisting a community after a hurricane, the nurse determines that the community members are in the dissillusionment phase of disaster recovery. What is the most appropriate intervention by the nurse when working with individual members?

Encourage them to verbalize their feelings.

A client presents to the emergency department in anaphylactic shock after a bee sting. What should the nurse do? Select all that apply.

Administer Diphenhydramine. Insert an intravenous line. Have respiratory therapy provide an albuterol treatment.

A nurse is transferring a client from the bed to a chair. Which action should the nurse take during this client transfer?

Help the client dangle his legs; After placing the client in high Fowler's position and moving the client to the side of the bed, the nurse should help him sit on the edge of the bed and dangle his legs. The nurse should then face the client and place the chair next to and facing the head of the bed.

While out of bed walking, a client reports dizziness and requests to go back to the room. The nurse obtains the blood pressure machine and obtains vital signs on the client. The client's pulse is 50 and the blood pressure machine reads 80/40 mmHg. The nurse notes the client is scheduled to receive verapamil and atenolol. Which actions by the nurse are best? Select all that apply.

Hold the medications. Call the healthcare provider and provide a report of the events and vital signs

A severe acute respiratory syndrome (SARS) epidemic is suspected in a community of 10,000 people. As clients with SARS are admitted to the hospital, what type of precautions should the nurse institute?

airborne precautions; Transmission of SARS can be contained by airborne precautions that include an insolation room with negative pressure, use of N-95 respirator, and use of personal protective equipment. The disease is spread by the respiratory, not enteric, route. Hand washing alone is not sufficient to prevent transmission.

The nurse notices that a cart being used to transport a client has a nonfunctioning clasp on the safety belt. What should the nurse do next?

Request that the transporter bring a different cart with a functional clasp.

The client in balanced suspension traction is transported to surgery for closed reduction and internal fixation of a fractured femur. What should the nurse do when transporting the client to the operating room?

Send the client on the bed with extra help to stabilize the traction.

The nursing student is having difficulty obtaining a mobile computer for the purpose of administering medications using the electronic medical record. The student has been reprimanded for delivering medications late in the past and wants to ensure timely administration. What action should the student take?

Speak to the instructor about the unavailability of mobile computers for medication administration, and request assisstance in obtaining one.

A nurse discovers that a hospitalized client with stage 4 esophageal cancer and major depression has a gun in the home. What is the best nursing intervention to help the client remain safe after discharge?

Talk with the health care provider (HCP) about requiring gun removal as a condition of discharge.

A client with toxoplasmosis and cytomegalovirus is confused and has been dislodging the I.V. access device. The client's scheduled to receive amphotericin B I.V. Which action would be most appropriate for the nurse to take?

Tell a nursing assistant to stay with the client during the infusion.

A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation, and incoherence of speech with frantic and aimless physical activity and grandiose delusions. Which would the highest priority goal in planning nursing interventions?

The client will show no self-harm or harm to staff.

The nurse is planning care for a toddler with a seizure disorder. Which item in the care plan should the nurse revise?

The nurse should revise a care plan that includes padded tongue blades. Nothing should be placed in the mouth during a seizure. Padded side rails will protect the child from injury during a seizure. The bag and mask system should be present in case the child needs oxygen during a seizure. Most seizures resolve in under 5 minutes. If they do not, then a dose of lorazapam can be administered. The healthcare provider will prescribe the correct dosage for weight and the parameters for administering.

Using the Morse Fall Risk scale (see exhibit), the nurse should initiate highest fall risk precautions for which client?

a 62-year-old client with a history of Parkinson's disease, admitted for pneumonia and receiving IV antibiotics, who has fallen at home but is able to ambulate with a cane and who during his hospitalization has gotten out of bed without calling for assistance; --> Using the Morse fall scale, risk factors for this client include history of falling, secondary diagnosis, ambulatory aid, IV/heparin lock, weak gait/transfer, and forgetting limitations (100 points). Client no. 1 is also high risk with a secondary diagnosis, history of falling, IV access, and confusion but is on bed rest (75 points). Client no. 2 risks include IV access and secondary diagnosis (35 points). Client no. 4 is at risk due to his IV access only (20 points).

The nurse is taking care of a client with neutropenia. Which nursing action is most important in preventing cross-contamination?

changing gloves immediately after use

A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is to:

ensure safety by initiating suicide precautions

What information would be important for the nurse to include in the teaching plan of a pediatric client and family prior to allergy skin testing? Select all that apply.

Anaphylaxis is a risk and precautions are taken. Allergens are applied to the skin.

A school-age child has just spilled hot liquid on his arm, and a 4-in (10-cm) area on his forearm is severely burned. His mother calls the emergency department. What should the nurse advise the mother to do?

Apply cool water to the burned area; To prevent further injury to the skin, the mother should apply cool water to the burn site. Doing so causes vasoconstriction, retards further damage to tissues, and decreases fluid loss. Keeping the child warm promotes vasodilation, increases fluid loss, and decreases blood pressure and, thus, circulation to the area. Applying ointment to the burn is contraindicated because it does not allow healing to occur and may need to be removed in the hospital. Only a clean cloth should be used to cover the wound to prevent contamination or decrease pain or chilling. If only the arm is burned, a call to 911 for emergency care is not necessary, but the mother should seek health care services immediately.

The nurse understands that the client who is undergoing induction therapy for leukemia needs additional instruction when the client makes which statement?

"I cannot wait to get home to my cat!"; The nurse identifies that the client does not understand that contact with animals must be avoided because they carry infection and the induction therapy will destroy the client's white blood cells (WBCs). The induction therapy will cause anemia, and the client will experience fatigue and will have to pace activities with rest periods. Platelet production will be decreased, and the client will be at risk for bleeding tendencies; oral hygiene will have to be provided by using a warm saline gargle instead of brushing the teeth and gums. The client will be at risk for infection owing to the decrease in WBC production and should report a temperature of 100° F (37.8° C) or higher.

The nurse develops a teaching plan for the client about how to prevent the transmission of hepatitis A. Which discharge instruction is appropriate for the client?

Ask family members to wash their hands frequently; The hepatitis A virus is transmitted via the fecal-oral route. It spreads through contaminated hands, water, and food, especially shellfish growing in contaminated water. Certain animal handlers are at risk for hepatitis A, particularly those handling primates. Frequent handwashing is probably the single most important preventive action. Insects do not transmit hepatitis A. Family members do not need to stay away from the client with hepatitis. It is not necessary to disinfect food and clothing.

When caring for the client with hepatitis B, which situation would expose the nurse to the virus?

a blood splash into the nurse's eyes; Hepatitis B virus is spread through contact with blood, body fluids contaminated with blood, and such body fluids as cerebrospinal, pleural, peritoneal, and synovial fluids; semen; and vaginal secretions. The risk of transmission of hepatitis B through feces is low. Touching the client without gloves is acceptable when there is no danger of contact with blood or body fluids. Recapping a used needle is a common source of needlestick injuries; needles should be properly disposed of uncapped.

A client has been hospitalized for 3 days and is now experiencing symptoms of pneumonia, confirmed by chest X-ray. Which action is a priority for preventing this type of pneumonia?

staff education for prevention of hospital-acquired pneumonia (HAP); A pneumonia occurring greater than 48 hours after admission is considered a hospital-acquired pneumonia (HAP). Predisposing factors include positioning, aspiration, malnutrition, prolonged hospitalization, and coma. Staff should be educated on these predisposing factors to prevent/minimize HAP. This is not CAP. Pneumovax should be given annually to high-risk groups and prior to admission and development of symptoms.

A client with acute bronchitis is admitted to the healthcare facility and is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the most likely cause of this sound?

The oxygen tubing is pinched; Pinching of the tubing used to deliver oxygen causes a high-pitched whistling sound. When the water level in the humidifier reservoir is too low, the oxygen tubing appears dry but doesn't make noise. A client with a nasal obstruction becomes more uncomfortable with nasal prongs in place and doesn't experience relief from oxygen therapy; the client's complaints, not an abnormal sound, would alert the nurse to this problem. A nasal cannula can't deliver oxygen concentrations above 44%

The school nurse learns that at least one of the children in the school has a new diagnosis of erythema infectiosum (human parvovirus) after developing a bright red facial rash. What interventions should be implemented to prevent a possible spread of the infection to other students in the school?

Teach everyone to implement hand hygiene; Erythema infectiosum (human parvovirus) is transmitted through direct contact with respiratory secretions. The client is contagious for a week prior to the appearance of the rash, but not after the rash appears, so quarantine of the diagnosed client will not reduce transmission. However, other children may already have been infected and hand hygiene can reduce the spread of the infection.

The nurse is reviewing the content of a prescription before giving it to a client. The nurse determines that the prescription is accurately written when which information is included on the prescription? Select all that apply.

healthcare provider signature frequency dose

A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission by saying:

"I'll stop being contagious when I have a negative acid-fast bacilli test."; A client with drug-resistant tuberculosis is not contagious when the client has had a negative acid-fast test. A client with nonresistant tuberculosis is no longer considered contagious when there is clinical evidence of decreased infection, such as significantly decreased coughing and fewer organisms on sputum smears. The medication may not produce a negative acid-fast test result for several days. The client will not have a clear chest X-ray for several months after starting treatment. Night sweats are a sign of tuberculosis, but they do not indicate whether the client is contagious.

A 26-year-old is being treated for delirium due to acute alcohol intoxication. The client is restless, does not want to stay seated, and has a staggering gait. What should the nurse do first?

Provide one-to-one supervision of the client until detoxification treatment can begin.

Which use of restraints in a school-age child should the nurse question?

to substitute for observation

When completing the preoperative checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first?

Inform the anesthesiologist.

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

check the equipment; A reading of 0 mm Hg indicates equipment malfunction. The nurse should check the equipment and report problems. Normal and stable ICP values are less than 15 mm Hg. Some pressure is always present in the cranial vault. The nurse shouldn't contact the physician to review the care plan at this time. The nurse needs to complete the assessment of the client and equipment before making a report to the physician.

What should the nurse teach the parent of a 3-year-old child with eczema to remove from the child's environment at home?

stuffed animals; For the child with eczema, which is commonly related to an allergic response, stuffed animals should be avoided because they tend to collect dust and are difficult to clean

A nurse applies standard precautions when caring for a client with human immunodeficiency virus (HIV). The nurse takes what action when applying standard precautions?

wearing gloves for providing mouth care

One evening, the client takes the nurse aside and whispers, "Don't tell anybody, but I'm going to call in a bomb threat to this hospital tonight." Which action is the priority?

explaining to the client that this information will have to be shared immediately with the staff and the health care provider (HCP)

Over the past few weeks, a client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure does not comply with a least restraint policy?

raising all side rails while the client is in bed

A client arrives on the psychiatric unit exhibiting extreme excitement, disorientation, incoherent speech, agitation, frantic and aimless physical activity, and grandiose delusion. Which nursing diagnosis takes highest priority for this client at this time?

risk for injury

A nurse administers incorrect medication to a client. After assessing the client, and completing an incident report, which is the priority action by the nurse?

Report the incident to risk management.

A client is on a stretcher and needs to be transported to another location. Which action should the nurse take to prevent a personal injury when transporting this client?

Stand at the head of the stretcher and push the device.

The nurse assists the client to the operating room table and supervises the operating room technician preparing the sterile field. Which action, completed by the surgical technician, indicates to the nurse that a sterile field has been contaminated?

Wetness in the sterile cloth on top of the nonsterile table has been noted; Moisture outside the sterile package contaminates the sterile field because fluid can be wicked into the sterile field. Bacteria tend to settle, so there is less contamination above waist level and away from the technician. The outer inch of the drape is considered contaminated but does not indicate that the sterile field itself has been contaminated.

A nurse discussing injury prevention with a group of workers at a daycare center is focusing on toddlers. When discussing this age-group, the nurse should stress that

accidents are the leading cause of death among toddlers.

Which variables should the nurse judge as likely to indicate high risk when assessing a client's potential for suicide? Select all that apply.

age 60 and older living alone previous suicide attempts financial distress; Risk factors for completed suicide are hopelessness, medical illness, severe anhedonia (loss of ability to feel pleasure), male gender, Caucasian or Native American/First Nations ethnoracial background, living alone, age 60 or older, unemployment, financial distress, or previous suicide attempt. Anger is a low-risk factor for suicide.

To prepare the community for the possible threat of anthrax, a nurse must teach that

anthrax can infect the integumentary, GI, and respiratory systems; Penicillin is the most common drug used to threat anthrax. Immunizations are appropriate only for those at risk of anthrax exposure.

A client has received numerous different antibiotics and now is experiencing diarrhea. What type of precautions should the nurse institute?

contact precautions; The nurse should initiate contact precautions to prevent blood borne infection through percutaneous injury. Extreme care is essential when needles, scalpels, and other sharp objects are handled. Airborne precautions are required for clients with presumed or proven pulmonary tuberculosis, chickenpox, or other airborne pathogens. Contact precautions are used for organisms that are spread by skin-to-skin contact, such as antibiotic-resistant organisms or Clostridium difficile. Droplet precautions are used for organisms such as influenza or Neisseria meningitides that can be transmitted by close respiratory or mucous membrane contact with respiratory secretions. Standard precautions include handwashing and use of a mask and gown.

What should a nurse do to ensure a safe hospital environment for a toddler?

Move the equipment out of reach.

A visitor to the hospital has a cardiac arrest. When determining to use an automated external defibrillator (AED), the nurse should consider that AEDs are used in cardiac arrest in which circumstances?

early defibrillation in cases of ventricular fibrillation; The American Heart Association and Canadian Heart and Stroke Foundation place major emphasis on early defibrillation for ventricular fibrillation and use of the AED as a tool to increase sudden cardiac arrest survival rates.

The children of an elderly client who has suffered an ischemic stroke have informed the nurse that an herbalist will be coming to their parent's bedside tomorrow to make recommendations for client's care. Which considerations should the nurse prioritize in light of the practitioner's planned visit?

ensuring any complementary therapies are safe when combined with his prescribed therapy

The nurse is assisting a healthcare provider in debriding a necrotic skin wound. The healthcare provider is using a plastic basin to collect the bloody supplies. When cleaning the area on completion of debridement, which nursing action is done after placing the supplies in a hazardous material bag?

Dispose of the plastic basin.

During rounds, a nurse finds that a client with hemiplegia has fallen from the bed because the nursing assistant failed to raise the side rails after giving a back massage. The nurse assists the client to the bed and assesses for injury. As per agency policies, the nurse fills out an incident report. Which activity should the nurse perform after finishing the incident report?

Include the time and date of the incident; The nurse should include the date and time of the incident in the incident report, the events leading up to it, the client's response, and a full nursing assessment. To prevent legal issues, the nurse should not attach the copy of the incident report to the client's records. Also to prevent litigation, the mistake should not be highlighted in the client's records. As the client report is a legal document, it should not contain the name of the nursing assistant.

A mother of a 5-year-old child who was admitted to the hospital has a Protection from Abuse order for the child against his father. A copy of the order is kept on the pediatric medical surgical unit where the child is being treated. The order prohibits the father from having any contact with the child. One night, the father approaches the nurse at the nurses' station, politely but insistently demanding to see his child, and refusing to leave until he does so. What should the nurse do first?

Notify hospital security or the local authorities.